HomeMy WebLinkAbout04485GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
_ 003 �I6NO
Owner's Name D`[' -+ � � i. . C Present Addressn�
System Location �---` �r(`)� �JD I '
Legal Description of Assessor's Parcel No. I — ? X' 2:7
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'DD— l(D73
f.
Permit 4 4 �, 5
Assessor's Parcel No.
This does not constitute
a building or use permit.
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SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Inspecto
FINAL SYSTEM INSPECTION AND APPROVAL (as installe
Call for Inspection (24 hours no ice) Before Covering Installation
System Installer-_
Septic Tank Capacity
Septic Tank Manufacturer or Trade Na t►�""
k
i
/ "'
Septic Tank Access within 8" of surface Illitrdliallnll�
IllaAbsorption Area i a I�
Absorption Area Type and/or Manufacturer or Trade
i Adequate compliance with County and State regulations/requmentsW!k$L\ilik
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. 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 I, 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.8arfield-countv.com
STAFF USE ONLY
PermitiF.-e�e:r''/7
Parcel No: (this information is available at the assessors office 970-945-9134)
ZVIIZl-3604.10
2
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
t a Port -IT p,.,Gee-- .c tra.e-‘e-F_
3
Lot Size: S Lot No: Block No: Subd./ Exemption:
l/ s g-
4
Owner: (property own
O L_
r)
MailingAddress
eZ6Z, NA\ra ilt>
Ph:
lei a el
Alt Ph:
` &,3 _ a 1(
5
k
Contractor:
4T Tct i L /xt rt ? %�/
Mailing Address ° O2 �a / ' jCD
e.att-)0.L.az-
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Alt Ph:
14o -3,0714d
6
Engineer:
Mailing Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: )i New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE:
'welling ( )Transient Use ( )Commercial or industrial )Non- Domestic wastes
( )Other - Describe
9
BUILDING OR SERVICE
TYPE: Si I1/4.Itv1'- &i f icy"
.,/.'7
Number of bedrooms j Garbage Grinder)Yes ( )No
iD
SOURCE & TYPE OF WATER SUPPLY: ( )WELL (SPRING , ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier: .1---.10445 r---1 Ot,E Haa-
1 I
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was en effort made to connect to the Community System?
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to let Ground Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL
PQSeptic Tank
( )Recycling, Potable
( )Other- Describe
FINAL DISPOSAL
QAbsorption trench,
PI�<)Wastewater pond
SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
14
BY:
Bed or Pit ( )Underground
( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES X)NO
16
PERCOLATION TEST
Name, address & telephone
Name, address & telephone
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
of RPE who made
of RPE responsible
soil absorption test:
for design of the system:
17
Applicant acknowledges
the local health department
issuance of the permit
reports submitted herewith
and are designed to
understand that any
that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by
to be made and furnished by the applicant or by the local health department for purposed of the evaluation of the application; and the
is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and
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
be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied for herein. I further
falsification or misrepresentation may result in the denial of the application or revocation of any permit .ranted based upon said application
perjur as provid-°' .y ,;... � L%j'//// p,n/}
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egal ac o for
ATUR DATE
STAFF USE ONLY
PermitiF.-e�e:r''/7
Perk Fee:
.,�y{}T�ottal feeelss::^�`')`�
Building
Perm'itt if:
Septic Permit #:
-
Issue Date: _
Building & Planning Dept:
APPROVAL DATE
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