HomeMy WebLinkAbout03633. -~
GARFIELD CDUNTY BUILDING AND SANITATION DEPARTMENT Permit N~ 3633
109 Bth Street Suite 303 Assessor's Parcel No.
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Glenwood Springs, Colorado 81801
Phone (303) 945-8212
This does not constitute
a building or use permit. INDIVIDUAL SEWAGE DISPOSAL PERMIT
Legal Description of Assessor•s Parcel No.----------------------------------
SYSTEM DESIGN
______ Septic Tank Capacity (gallon) ______ Other
Required Absorption Area -See Attached //~
Percolation Rate (minutes/1nch)pm~er of edr°;:Jjs (or other)
Special Setback Requirements·
Date _____________ 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 andfor Manufacturer or Trade Name --------------------------
Adequate compliance with County and State regulations/requirements _____________________ _
Other ___________________________________________ _
Date _____________ Inspector ___________________________ _
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
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.
This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection 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.
An~~person who conitructs, alters, or installs an 1nd1v1dual sewage disposal system in a manner which involves a knowing and material
variation from the terms oi'\e8Cifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine -6
months in jail or both).
~ . ..
INDIVIDUAL SEW AGE DISPOSAL SYSTEM APPUCAITON
OWNER Bala ~ /1,uf!s ki9b&,
ADDRESS 8-0({2 P .. :I&# ().!¢ -CJ<.,.~
CONTRACTOR 6,c..cd /t.--5
PHONE 1/7 'i:lei IS
ADDRESS /L.{ u <l£fnd R..t -tZ1 '2le-
PERMIT REQUEST FOR 94 NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACU.ITV;
NearwhatCityofTown tAk11.,,,,...J. V"'l"1., Sil.eofI..ot 2(, {./.er-<-.";
Legal Description or Address C. ~ l J.S <;;;' -S .
WASTES TYPE: ()d) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTIIER. -DESCRIBE
Bun.DING OR SERVICE TYPE: ~. f-·---------------
Number of Bedrooms~;.._ __________ _ Number of Persons -tf-+------
OQ) Garbage Grinder ( ) Automatic Washer ~ Dishwasher
SQURCE AND IYPE OF WATER SUPPLY: Q<J) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __________ _
Was an effort made to connect to the Community System?_.JJ:di.;._ __________ _
A site plan ls required to be submitted that Indicates the followinp MINIMUM distangs;
Leach Field to Well; 100 feet
Septic Tank to Well; 50 feet
Leach Field to Irrlgadon Ditches, Stream or Water Coune; 50 feet
Septic System to Property Lines; (septic tank &leach field)ll feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDmONS:
Depth to first Ground Water Table'----------------------
Percent Ground Slope. ________________________ _
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' TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
-( l(l) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
~) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
Wll..L EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF 1llE STATE?
PERCOLATION TEST RESULTS: (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
Minutes. ____ per inch in hole No. 2 Minutes. _____ _,per inch in hole NO. _
Name, address and telephone ofRPE who made soil absorption tests: ____________ _
Name, address and telephone ofRPE responsible for design of the system: ___________ _
Applicant acknowledges that the completeness of the application is conditional upon such further mB!Vfatory and
additional tests 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 COiiect to the best of my knowledge and belief and are designed to be relied on by the local depmbneut of
health in evaluating the same for purposes of issuing the permit applied for herein. I further understand that any
tillsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
upon said application and in legal action for perjuJy as provided by law.
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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