Loading...
HomeMy WebLinkAbout0437415150 ivFwgD, GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 4 3 7 4 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT po PROPERTY j re `��lS-Cl( r. Owner's Name nab- ab- Present Address Phone 33 System Location 0 35 moi C1 'fC CAw5 -194-o© -cam Assessor's Parcel No. This does not constitute a building or use permit. Legal Description of Assessor's Parcel No SYSTEM DESIGN Septic Tank Capacity (gallon) Other Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: Date Inspector FINAL SYSTEM INSPECTIO AND APPROVAL (as install Number of Bedrooms (or other) Call for Inspection (24 hours ntice) Before Covering Instil ation System Installer Septic Tank Capacity Septic Tank Manufacturer or Tr: de Name Septic Tank Access within 8" of s rface Absorption Area Absorption Area Type and/or Manufac urer or T -de Name Adequate compliance with County and State regulations/requirements Other Date Inspector RETAIN WITH RECEIPT RECO S AT CONSTRUCTION SITE I_rb , k' l) *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 aviolation 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 ($500.00 fine -6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT Garfield County Vendorname and Address Vendor Number Purchase Order # �� J L _ S�.X-Nra�' ae� 0.n, 7 S atV '7[ th 114-4A.1►L Special Instructions For Warrant Invoice Date Vendor invoice Number Fund Dept Sub Dept Account Project # (if applicable) Line Item (64 Characters or Less) Brief Description 64 Characters or Less) Invoice Dollar Amount eebeS1-Oil t,. o$ 161D r 01 0 3y� • 3332.1" 661 Cdaik aQ�o�}. f596:7 1 p -tet 0 c sa f ..1 4 75-7, L Prepared By: Department Head Approval: 9(c5/° Financial Management Guide Limits: (Needs to be signed by CountyAdminister if Over $10,000) DATE: DATE: Total Is-5t.�1 Posted By: Date Stamp: (Accounting Use Only) Invoice Accuracy Verified By: 2008 AP Voucher.xls INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER sen—v—)ke. ADDRESS -16/q G( ,tA,oi.3b-G CONTRACTOR ADDRESS PHONE PERMIT REQUEST FOR (t,—KW 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:s Near what City IATown C4PivltAu Si ; Size of Lot '� Legal Description or Address G,,s f :r,{ { (o. � (p s C. -- I � C (el --..)v �'� "„m j WASTES TYPE: ( ,WELLING Sia cl2 ke) ' ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER — DESCRIBE BUILDING OR SERVICE TYPE: Number of Bedrooms 3' Number of Persons 1 (Garbage Grinder (Automatic Washer (.dishwasher SOURCE AND TYPE OF WATER SUPPLY: (.)-WELL ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: yvl Was an effort made to connect to the Community System? fro 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: 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: ,iD th to first Ground Water Table ercent Ground Slope 2 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (, . SEPTIC TANK ( ) VAULT PRIVY ( ) PIT PRIVY ( ) CHEMICAL TOILET( ) AERATION PLANT ( ) VAULT COMPOSTING TOILET ( ) RECYCLING, POTABLE USE INCINERATION TOILET ( ) RECYCLING, OTHER USE OTHER -DESCRIBE /FJNAL DISPOSAL BY: ( ) ABSORPTION TRENCH, BED OR PIT UNDERGROUND DISPERSAL ABOVE GROUND DISPERSAL OTHER -DESCRIBE ( ) EVAPOTRANSPIRATION ( ) SAND FILTER ( ) WASTEWATER POND WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Na PERCOLATION TEST RESULTS: (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 Minutes per inch in hole No. 2 Minutes per 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 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 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 PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! 3 0707 Designate North Arrow Your Neighbor's Name & Address �.� Your Plot - Shape to Fit (No Scale) is4rp icz Locate 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) eric c.lwpwin60\wpdocslplot.loc