HomeMy WebLinkAbout04406GARFIELD 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 T-n(0Ck (,)06m
System Location
Present Address D)'1
62- Uic
Permit0 45
Assessor's Parcel No.
This does not constitute
a building or use permit.
Phone > �.�.)
Legal Description of Assessor's Parcel No. ,� `5. Z - j -r n-, ) ��
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
Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
P ,/d/74 7 � r
System installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
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 //1(.?:// ,.� �%(C ij �p7 .r � i• -L ./..:1-7,17:<./
i.�%/
7
Date Inspector
r -a iJ ;✓'
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).
While - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER E n 6, a.. 0
ADDRESS
CONTRACTOR P. f-rsv.v
g- as
us4
Lbo.ot als" 6L too PHONE I77- S 60S
70
ADDRESS See #4 c k v i 1
PHONE
PERMIT REQUEST FOR 4 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 FACILITY:
Near what City of Town /0 ..*:les We,r a� arae-
� � 4e- isSize of Lot !I/r,�,
Legal Description or Address
WASTES TYPE:
( ) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
(>4) OTHER -DESCRIBE /1; ar 1 e i poral i,C , y,e ,s; .t., (LTi )
BUILDING OR SERVICE TYPE: 41.TE .)-1-•
Number of Bedrooms Number of Persons J4
( ) Garbage Grinder Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (>c WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST .COMMUNITY SEWER SYSTEM: 1 s-mn/7es
Was an effort made to connect to the Community System? yes
A site • lan is re uired to be submitted that indicates the followin ' MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
414
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) SEPTIC TANK ( ) AERATION PLANT (X) 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
UNDERGROUND DISPERSAL
ABOVE GROUND DISPERSAL
OTHER -DESCRIBE gam lett 46
wa.s{e- tui `
EVAPOTRANSPIRATION
SAND FILTER
WASTEWATER POND
i
��++4.0 t to
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? do
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes Net per inch in hole No. 1 Minutes
Minutes ,v -c1/4. per inch in hole No. 2
Wec
per inch in hole No. 3
Minutes 'kickper inch in hole No.
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE 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 maybe 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 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
falsification 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 . ---'' Date en%It,/ moo 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY? ?
3
Designate North Arrow
Your Neighbor's
Name & Address
Your Plot - Shape to Fit
(No Scale)
5
4ae+ (i
Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
Your Neighbor's
Name & Address
County Road (Note the Road Number and Name)
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SCALE: 1' = 60*
DATE: 04 -20-07
Drawn By, D.R.B.
Revised: 02-27-07 O.RB
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EnCana OIL & GAS (USA) INC.
LOCATION LAYOUT FOR
WELL PAD D27 595
SECTION 27, TSS, R95W, 6th P.N.
NW 1/4 NW 1/4
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6421nw PIE
5
7
LECENO:
i - OVERFLOW
2 - SEWER TANK
.Y - Llrr STATION
4 - SERER EINE
2 - WA 7FR MNK
5 - FREEZER
7 - STORAGE
2 - GENERATOR
- 'r'uEL
7O - TRANSFORMER
UINI'AH ENCrN BRIM & LAND SURVEY%NNC
85 .Sa 200 teat • Vernal: °.ilt,sh 84078 • (495) 789-iW0
PROPOSED) LOCATION:.
927 595 MAN. CAMP}
DRIVING CIRECI3OI.`S TO 0:47 595 MAN CAMP
PRGCEEO IN A NORTHWESTERLY. 1HEN NO1THEAS1'ERL?
DIRECTION FROM 7ARAG1 U1E. COLORADO
APPROX1>RATELT 11.3 MILES
TO FHE JUNC110N OF IMS ROAD AND AN EI<ST1134G
,ROAD TO THE NORTHEAST: TUItN RIGHT AND PROCEED
tN A NORTHEASTERLY DIRECTION APPROXIMATELY S.6
MILES TO ME BEGINN3/W Of THE EXISTING ACCESS
ROAD TO ME NORTH; TURN LEFT AND CON11"NUE IN A
NOTTNEPLY. THEN NO1TTH',4SSTERLY DIRE.T TIOU
AppR0143142!..T Y :25 iO THE E CiST1NG LCCAFION.
1C)TAL DISTANCE FROM 1'ARACHVTE COLGRAD-333 THE
EXISTING LOCATION IE APRROXIMATELY 11.7 MITES.
l4A44 CAMP trl(=AIEON:
LATITUDE StI 3E 25.12'
LONGITUDE +DS .2' 52. CT
ELEVATION 5)53
LEGEND:
Q PROPOS : 1) LOC NT 1ON
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Fainut h Ett2ineerinng Llind 5t1r-ti"i,?!tng
'3S S< t.Clt 21.)() Ewit vr.rre.tB. L tett 71-5.018
(-63:5} 1739-110 11 11. -"AX (43{) 789-18'I3
EnCana OIL & GAS USA) INC.
1)27 595 MAN CAMP)
SECTION 27, ESS. R95\V, €)€' t PM.
NW 1!4 Nth` 1/4
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SCALE: I:1OOM J IRAN! B1: J.L.C.: REVISED: 00-00.00