HomeMy WebLinkAbout04425GARFIELD 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 Name
ie
System Location
Ad, d' y
Permit v,. ; .�
Assessor's Parcel No.
This does not constitute
a building or use permit.
Present Address 0-37? ? -5 C, RVAA , ' eezA16- RhoneA
o399' Mae ..5100X6_5* i /11 r (2, / Z :
Legal Description of Assessor's Parcel No
:-""
SYSTEM DESIGN
// - 079
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
C 77, /`-
- /17. `./ 4,&V /Y
Special Setback Requirements:%` , '/, //t/ CO a€- q,;,9
7 Date - Inspector`~
Required Absorption Area - See Attached
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 - '= �✓ T `/ 2 0
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 k r! ,-
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. Alt 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 }ail or bottry.--'
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. arf field -county. corn
1
Perk Fee:
c � d sU
Parcel No: (this information is available at the assessors office 970-945-9134)
2
Septic Permit #:
4L4a-s
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
Q - - Alb APs . Cel.cti s' r i rays Rw.AcL. 440 . er47-4
3
APPROVAL DATE
C: r; I,- c gwAa,
Lot Size:r Lot No: earce, Block No. SC Cedar
4
Owner: (property owner)
f -r
\eSI•it)e .9eL
Mailing Address
(20i3e)xar i- C'
O
Ph:
9706 `5-
Alt Ph:
67r -9s
5
Contracts}:
---"Te-r ,. L..-..
Mailing Address
C, i , . ,R-'"7 R t IL-
Ph:Alt
Ph:
6
Engineer: t
Mailing Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: t New Installation ( ) Alteration () Repair
8
WASTE TYPE: 'Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( Other - Describe
9
BUILDING OR SERVICE TYPE: `m '"
Number of bedrooms ? Garbage Grinder ( )Yes ( )No
10
SOURCE & TYPE OF WATER SUPPLY: ELL ( )SPRING ( }STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier:
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM
Was an 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 1s 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:
{Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
15
Will effluent be discharged directly into vraters of the state? ( )YES - NO
16
PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the Peron tion 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
understa d that any falsification or misrepresentation
and le, action for perjury,.ro id by law,
r
— 4,'f
the application is conditional upon such further mandatory
by the applicant or by the local health department
conditions as deemed necessary to insure compliance
by the applicant are or will be represented to
of health in evaluating the same for purposes
may result in the denial of the application or revocation
and additional test and
for purposed of the evaluation
with rules and regulations
be true and correct to the best
of issuing the permit applied
of any permit granted
,..,,
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
for herein. I further
based upon said application
_.s
DATE
aa-" �;7i`I�:�''i-�[�,� - /
�o�
STAFF USE ONLY
Permit Fee:
' (3o
Perk Fee:
c � d sU
Total fees:
1 rA3 . Go
Building Permit #:
ID n. y
Septic Permit #:
4L4a-s
Issue Date:
Building & Planning Dept:
APPROVAL DATE