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Home My WebLink About03679;;z;: ! r~ ~ j ~ " ! • GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 109 8th Street Suite 303 Glen-od Springs, Colorado 91601 Phone (303) 945-8212 , INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY PermH N~ Assessor's Parcel No. This does not constitute a building or use permit • " ' """"' ~2a\~t-·--lroln1 tta 14 ~ CnsJo~.cil)I-'llnld--' System Locatio~~ ~ ~ ~r£G>?J \e. ~--019-l kQ) ! Legal Description of Assessor's Parcel No. ____ J~_1_2$~+b~O~S'~~/ _-~0~0_-_o_~--------------- I . ' l i • ' SYSTEM DESIGN I-' so L-=~---Septic Tank Capacity (gallon) ______ Other ______ Percolation Rate (minutes/inch) Number of Bedrooms (or other) ____ _ Required Absorption Area -See Attached Special Setback Requirements: Date _____________ Inspector ___________________________ _ FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering"lnstallation Septic Tank Capacity ____ ___.1?,_,.,4(.....__,F..___....;:;~.:.· __ _,7?-y"-""'-' -''"i_-_i..;c=>,..__ _ _./_,_ri;t:t'-'-=I(~------------ Septic Tank Manufacturer or Trade Name-------------------------------- Septic Tank Access within 8'' of surface -------------------------------- Absorption Area---------------------------------------- I C' Absorption Area Type and/or Manufacturer or Trade Name -~0-' 0~_~111f'>4=~~c..~a. .... ------------------ Adequate compliance with County and State regulations/requirements, _____________________ _ Other __________________ -rr---il--~-------fi-'--,~------------------Date~fo~---~'-:-_,_7_-~(_~)_--,~ ___ lnspector --1'#r'-'-"'._.__ __ )_'7• ~c ... " ... C_1_7J~• ~·,~------------- RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE •CONDITIONS: 1. All installation must comply with all requirements of the Cok>rado State Board of Health Individual Sewage Disposal Systems Chapter 25. Article 10 C.R.S. 1973. Revlaad 1984. 2. This permit is valid only for connection to structures which have fully complied with County zoning~ building requirements. Con- nection to or use with any dwelling or structures not approved by the Building and Zoning office B.hall auto.rnatically 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). While -APPLICANT Yellow -DEPARTMENT ., r ' INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION CONTRACTOR _________________________ _ ADDRESS ______________ _ PHONE _______ _ PERMIT REQUEST FOR ( ) NEW INSTALLATION ()Q_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 FACILITY: Near what City of Town.__._N~e'-'w_,,__ ..... C..,,a ...... sw..rt-1-'...:e."--________ .,.Size......,,,o""'f Lo=t ----"-' ._,2-~S---"'a=c<....:v_,,('-"'~'- Legal Description or Address ----+{g:faf..,J .......... ..._(__,,L=-=-~-J_llf_,_·_ .... JJ=w;;;.__C_a.._~+_(-e..-"-------- WASTES TYPE: _J><{ DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( )OTHER-DESCRIBE. ______________ ~ BUilDING OR SERVICE TYPE:__,Sc.UI n4~411.i...e __,_P-"'tl"-'l'Yl~lc..::L..-"'yl---'Vt'-"-"-D!..!.YYte...-.:=.. ________ _ NumberofBedrooms __ 4-__________ ~ ( -.j) Garbage Grinder ( 0 Automatic Washer SQURCE AND TYPE OF WATER SUPPLY: (~ WELL Number of Persons-"""'----- (x.) Dishwasher ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: ______ . ________ _ DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:-....:5::....__YY\._L_\-=e"-'s._· ------ Was an effort made to connect to the Community System?--'-N:...O'-------------- A site plan is required to be submitted that indicates the following MINIMUM distances: Leach Field to Well: 100 feet Septic Tank to Well: 50 feet Leach Field to Irrigation Ditches, Stream or Water Course: SO feet Septic System to Property Lines: (septic tank &leach field JlO feet YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WllL NOT BE ISSUED WITHOUT A SITE PLAN. GROUND CONDITIONS: Depth to first Ground Water Table ____________________ _ Percent Ground Slope ________________________ _ 2 "1'¥1'"':~ ' ' · • TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (X) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT ( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE ( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE ( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE FINAL DISPOSAL BY: (X.) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION ( ) UNDERGROUND DISPERSAL ( ) SAND FILTER ( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND ( ) OTHER -DESCRIBE WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ______ _ PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) Minutes. ____ -Jler inch in hole No. 1 Minutes ____ _,,er 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 mandatory 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 p\JrpOsed 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 com:ct to the best of my knowledge and belief and are designed to be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied for herein. I further understand that any fiilsification 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 perjury as provided by law. signed ~Ja,1tti fu zW PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! 3 eKIM:JC .PL~./-r,>-i_f ·~ ·J • .~ ( ~ Designate North Arrow Your Plot -Shape to Fit (No Scale) Your Neighbor's Name & Address Your Neighbor's Name & Address ' Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house, septic tank & system, detached garages, and driveway. If a change oflocation is necessary, you must submit a corrected drawing, before a Certificate of Occupation will be issued. County Road (Note the Road Number and Name) enc c·\wpwin60\wpdocs\p1ot.loc /'-'iA)