HomeMy WebLinkAbout044893.60
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY_
Owner's NamR//1 r (/ (
System Location
Permit n
Assessor's Parcel No.
_
1L tP Cii , Present Address1 DO RTh 6 �✓
VI Alf} • To r tCriut )
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Legal Description of Assessor's Parcel No
SYSTEM DESIGN�
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other) ,-&-141
Required Absorption Area - See Attached / w� /,{, 1 r d (r.)l1-f--e.. Z_. y" ' lie et -
Special Setback Requirements:
Date (/-, A Inspector�:• r` I,( ('�1 % a 4-
This does not constitute
a building or use permit,
Phans If.)� t
c51g 163.s
77-Lp
FINAL
SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer (..
Septic Tank Capacity /0770
0
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area r ; .• to )
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements /0/",-1
Other
'?�
Date ri 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. 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.
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: 970-945-82121 Fax: 970-384-34701 Inspection Line: 970-384-5003
www. ga ietd-county.com
1
Parcel I\10: (this information is available at the assessors office 970-945-9134)
t`D5 3'3 i O oO2-
2
�.- �'
•
Job A fess: (if an address as not been as ' ned ise provide Cr, Hwy or Street Name & City o and legal description
3
Lot Si e: Lot No: Block o:
4---
Subd.l Exe tion:
(f6 — 2---) '' DE)
B ding & PI=.
4
Owner:
wwn�er_::(property owner) r j
? = � a `'� _
Mailing Address
�}I
e t�1b--- o ? 2,o
Ph: `_
/ S 7 6
Alt Ph:
Gam' R G✓ 5 S Q.
5
Cogt(acto�
0
Mailing Address
Ph:
Alt Ph;
6
Engineer:
Mailing Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: ( )Dwelling ( )Transient Use .(> Commercial or industrial ( )Non- Domestic wastes
( )other -- Describe
9
BUILDING OR SERVICE TYPE: 50-0_06'
Number bedrooms 0 Garbage Grinder ( )Yes3No
10
SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
SWELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
of supplier:
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
it
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:,A,.
Depth to 15' Ground
i
Water Table ,4"7 Percent Ground Slope 2:•-,0
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISOs) 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:
(`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 ,)NO
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 b- '•d on by the loal department of health in evaluating the same for purposes of issuing the permit applied for herein. I further
understand that . ° falsifi.:tis... s . isrc4resentation may result in the denial of the application or revocation of any per granted based upon said application
and legal act for :s , al i -d , law.
oWNE •i~ `r T • E DATE
STAFF USE ONLY
Permit Fee•
Perk Fee:
\D0 r
Total fees:
\
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•
Building Permit #:
10--Zel--.
Septic Permit #:
PAP
I
Issue Date:
(f6 — 2---) '' DE)
B ding & PI=.
,t•
APPROVAL
DATE