HomeMy WebLinkAboutApplication- Permit(0-'-o9
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 401 4660
Glenwood Springs, Colorado 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY pp [�
Owner's Name I�Q�� cc ezi IL,nobje d -
System Location,R" �OUt Id Mee .\Fb (�
Legal Description of Assessor's Parcel No. CTI — c,��—oO 113
Permit
Assessor's Parcel No.
This does not consti
a building or use pe
Present Address
SYSTEM DESIGN
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Inspector
Other
Number of Bedrooms (or other)
FINAL SYSTEM INSPECTION AND APPROVAL (as4nstalled)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or/ anufacturer or Trade Name
Adequate compliance with/County and State regulations/requirements
/
a
Other
Date
CONDITIONSrr•
1. All insfa -tion must comply with all requirements of the Colorado State Board of Health Individual Sewage
Disposal Systems Chapter 25, Article 10 C.R.S. 1973, Revised 1984.
2. ytlis permit is valid only for connection to structures which have fully complied with County zoning and
building requirements. Connection to or use with any dwelling or structures not approved by the Building and
Zoning office shall automatically be a violation or a requirement of the permit and cause for both legal action
and revocation of the permit.
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which
involves a knowing and material variation from the terms or specifications contained in the application of
permit commits a Class 1, Petty Offense ($500.00 fine - 6 months in jail or both).
Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
White - APPLICANT Yellow - DEPARTMENT
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GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8`u Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www.aarfield-coup .com
1
Fee:
I(ND
Parcel No: (this information is available at the assessors office 970945.9134) C
2
ermit k: (.....P1
Job Address: (if an address has not been als§igned, please pro ' e Cr, Hwy or Street Name & City)orand legal description
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Building
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Lot Size:Lot Block No: Subd./ Exemption:
/O ✓Gc. ~—°145f' e '� 77/.1 ',-/dG—"O yo7
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APPRO AL DATE
Own (property owner)
/�e2>/ 00/i/as
Mailing Address / /
0/ 83 &cw ,1696;6=p�
Ph: (9 70 6:25"
0 85/
Alt Ph:
5
Contractor:
Mailing Address
Ph:
Alt Ph:
6
Engineer:
Mailing Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: �) New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: (welling ( )Transient Use ( )Commercial or industrial )Non- Domestic wastes
( )Other — Describe
9
BUILDING OR SERVICE TYPE:
Number of bedrooms . q Garbage Grinder ( )Yes (1
10
SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
(t3WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
of supplier:
11
DISTANCE TO NEAREST COMMUNITY SEWER
Was an effort made to connect to the Community System?
SYSTEM:
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1st Ground
Water Table Percent Ground Slope
13
TYPF..OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
( eptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other- Describe
14
FINAL DISPOSAL BY:
( )Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES (*K0
16
PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the Percolation Test)
Minutes per inch in hole No.1 Minutes per inch in hole
No.3
No._
Minutes per inch in hole No.2 Minutes per inch in hole
Name, address & telephone of RPE who made
Name, address & telephone of RPE responsible
soil absorption test:
for design of the system:
17
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by
the local health department to be made and furnished by the applicant or by the local health department for purposed of the evaluation of the application; and the
issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and
reports submitted herewith and required to be submitted by the applicant are or will be represented to be true and correct to the best of my knowledge and belief
and are designed to be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied for herein. I further
understand that a .Isif : i.n or tr1 reps` talion may result in the denial of the application or revocation of any permit granted based upon said application
and legal act'r . ped r, aw. —
rite.
OWN ' IGNATU- DATE
t
STAFF USE ONLY
Permit Fee:Perk
13
Fee:
I(ND
Total fees: -
13
Buildi
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Septic Permit #:
Issue Date:
Building
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APPRO AL DATE
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