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HomeMy WebLinkAbout04526GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT iNice 108 Eighth Street, Suite 401 Glenwood Springs, Colorado 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY t� Owner's Name Y,� ►�/ I PresentAddressl',11�©0 System Location L-10\0 Ct 22/�"'tr-`i'1C CD ?N7 Description of Assessor's Parcel No. » \a* ,' vim✓((''�� ' (X ' ?N/ Permit Assessor's Parcel No. 4526 This does not constitute a building or use permit. SYSTEM DESIGN Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: Date Inspect Other Bedrooms (or they) PhoneCraWr(jij FINAL SYSTEM INSPECTION AND APPROVAL (s installed) Call for Inspection (24 hours notice) Before Covering Inst Ilation System Installer Septic Tank Capacity Septic Tank Manufacturer or Trade Name Septic Tan Access within 8" of surface Absorption Are Absorption Area Typ@and/or Manufacturer or Trade Name Adequate compliance uv# h County and State regulations/requirements Other Date \ Inspector RETAIN WITH R€ECEIP�ECORDS 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 8th Street, Suite 401, Glenwood Springs, Co 81601 Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003 www.qatheld-county.com 1 �3 Parcel No: (this information is available at the assessors office 970-9459134) —00µ ^ Ore \ 2 1 '�Bu'Iding mit i 14 1 Job Address: (if an address has not bean assigned, please provide Cr, Hwy or Street Name & City) or and legal description 40/0 cr2226 /girlie ea 3 Lot Size: Lot No: / Block No: ..�_ Subd./ Exemption: Li 3.3 4e . .._-.,_. 4 APPROVAL ( DATE Owner: (property owner) t errer� f`loocd Mailing Address 6j4s-o low Ckt2no . 1cfit co Ph: iia --0,3y/ Jg' Alt Ph: 5 Contractor: Serra cens'fa Mailing Address (rr3nfi 262t retitI e2tee/kaa OP. psad- .z®/ L*SC Alt Ph: no•zg3•372-p 6 Engineer. Mailing Address Ph: Alt Ph: 7 PERMIT REQUEST FOR: )4 New Installation ( ) Alteration ( ) Repair 8 WASTE TYPE: (Dwelling ( )Transient Use ( )Commercial or industrial )Non- Domestic wastes ( )Other — Describe 9 BUILDING OR SERVICE TYPE: Sing -r -i. ea "-uos Numberdfbedrooms .4 i Garbage Grinder( )Yes ( )No 10 SOURCE & TYPE OF WATER SUPPLY: (X)WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN If supplied by COMMUNITY WATER, give name of supplier: 11 DISTANCE TO NEAREST COMMUNITY SEWER Was an effort made to connect to the Community System? SYSTEM: S rn.� O -t rr-'tsr-'i"e-r YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth to *Pt Ground Water Table Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED: *Septic 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: '(X)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 j0 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 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 falsification _rno isrepresentation and".by . r'. • .:: oyid er r 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 be true and correct to the best of my 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 Dc rt est. 1z lr3v eQ %�� t�' ccinS SIGNATURE DATE STAFF USE ONLY Permit Fee: �3 Perk Fee:((11 l i�V® Total fees: 1 '�Bu'Iding mit i 14 1 t \T3- - Septic Permit #: Issue Date: Buil ( n r j� y e.t: APPROVAL ( DATE