HomeMy WebLinkAbout04542GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 401 4542
Glenwood Springs, Colorado 81601
Phone (970) 945-8212
ti
INDIVIDUAL SEW GE ISPOSAL PERMIT
PROPERTY
Owner's Name1_-J
PjresenntAddres
System Location s ,lJ 27/ --Res -3\4
'7 (��
Legal Description of Assessor's Parcel No. 21 17 —2 / — II c 1kp
Permit
Assessor's Parcel No
_alp (fie
This does not constitute
a building or use permit.
Phone ` -(?-7
SYSTEM DESIGN reMQ\S (Z OS
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Other
Number of Bedrooms (or other)
Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
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 Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
CONDITIONS:
1. All installation 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. This 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).
White - APPLICANT Yellow - DEPARTMENT
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8ih Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www.earfeld-countv.com
1
Perk Cee:
Parcel No: (this Information is available at the assessors once 970-945-9134)
2177-262-00-956
2
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
Section 27 T6S R93W. 6TH P.M.
3
Lot Size: Lot No: Block No: Subd.l Exemption:
1480 Acres NA 00 NA
4
u1---
Owner: (property owner)
Bureau of Land Management
Mailing Address
50629 Highway 6 & 24
Glenwood Springs, CO 81601
Ph:
970.947.2800
Alt Ph:
NA
5
/2-/Act0g
Contractor:
Mountain West Oil Field Services
Mailing Address 864 20 RD #F
Fruita, CO 81521
Ph:
970.858.8859
Alt Ph:
NA
6
Engineer: Christopher F. Hale
Mountain Cross Engineering
Mailing Address 826 1/2 Grand Avenue
Glenwood.Springs,.CO.&460.1_...
Ph:
. 970:945.5544
Alt Ph:
7
PERMIT REQUEST FOR: (9) New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: ()Dwelling ( )Transient Use ( )Commercial or industrial )Non- Domestic wastes
( )Other - Describe
9
BUILDING OR SERVICE TYPE:
Number of bedrooms Garbage Grinder()Yes ( )No
10
SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
( )WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
of supplier: Vault and Haul System -Water received from COPHEcerlifed wale(hauler.
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 14 Ground Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1505) PROPOSED:
( )Septic Tank ( )Aeration Plant ()Vault ( )Vault Privy ( )Composting'Toflef
( )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 (00ther-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe Water Hauled to municipality
15
Will effluent be discharged directly into waters of the state? ( )YES LINO
16
PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer 4 the Engineer.doeslhaPercolation Testy...
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
the local health department to be made and furnished
issuance of the permit is subject to such terms and
reports submitted herewith and required to be submitted
and are designed to be relied on by the local department
understand that any .Isiflcatior .. misrepresentation
and legal acf i jury 4. ided by law.
of the application is conditional upon such further mandatory and additional test and reports as may be required by
by the applicant or by the local health department for purposed of the evaluation of the application; and the
conditions as deemed necessary to insure compliance with rules and regulations made, information and
by the applicant are or will be represented-to.betrue-and-correctto-thsbesfofmy knowledge -and -belief
of health in evaluating the same for purposes of issuing the permit applied for herein. I further
may result in the denial of the application or revocation of any permit granted based upon said application
U
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OWNERS URE 1 .AT
STAFF USE ONLY
Pe mit Fee: I ems—
Perk Cee:
Total fees:
C�
Building Permi#:
Septic
Permit #:
u1---
ssue Date:
12< C51016
Build'-
1
g & PIan
i`dDept:
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APPROVAL DATE
�-----tom
1 k MIo Pit T A I
Approxlmatei
Location of
PIPELINE
(not verified
by survey)
Mal
Irrwpij
Pits
change
room
R
Waste Water -4]
Fresh Water-€
Directional
Trailer
f
Portable
Meeting g'toil@ts
R g Manager (Thom
Frailer
Trailer
Man
1"=100'
_ 11111
SI111_-
0
100
Surface Disturbance Area
Proposed 5.621 acres
Actual 5.414 acres
ate^
1, Kenneth Scott Thompson, a registered Professional Land Surveyor
In the State of Colorado, do hereby state that the Survey shown
hereon was prepared under my supervision and has been prepared
solely for the purpose of depicting the location of Improvements on
the site shown as surveyed on October 8, 2008.
This statement Is not a guaranty, either expressed or implied.
RIVERCITY
CONSULTANTS
744 Horizon Ct.
Sults 110
Grand Junction
CO 81506
970-241-4722
Drawn:kst IChecked:dat'Oct I5, 20081
5:\PROJEGTS\1086 EnGana\OO2 H21NWW2lNWasbullt.pro
Woo awe
Ex 187
Proposed Location
Well Pad (H27NW)
EnCana Oil 6 Gas inc.
?u=sem
. rm1Samey g gat.
(435) 781.2501
188 Nonh Vunai Ave. Vernal, Utah 84078
= Legend =
® Existing Road
Well Pad (H27NW)
SEC. 27, T6S, R93W, 6th P.M.
SHEET
VOWS
OF 11
Proposed Location
Well Pad (H27NW)
spring
EnCana od&Gas Inc
Well Pad (H27NW)
SEC. 27, T6S, R93W, 6th RM.
7w -S,
c/aadSszoepeg Av.
(435) 781.2501
180 Nath Vernal Ave. Vernal, Utah a4W8
= Legend =
allelliallirnalaa Existing Road
SHEET
10
OF 11
Proposed
Access *2700'
Proposed Location
Well Pad (H27NW)
Well Pad
(K21NW)
J
P'
Ile In at
Existing
Pipeline
EnCana Oil &Gas Inc.
Well Pad (H27NW)
SEC. 27, T6S, R93W, fith P.M.
{
7u-Sern
Zeta' Savo*? %mc.
(435) 7E-2501
180 NUM Vernal Ave. Vernal, than 84018
_ Legend _
-TM---mom
Existing Road
---- -----_ Proposed Access
mom .� ®^ e.» Proposed Gas Line
SHEET
11
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