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Home My WebLink About03710GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 109 8th Street Suite 303 Glenwood Springs, Colorado 81801 Rhone (303) 945.8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Owner's Nam System Loca Legal Description of Assessors Parcel No. SYSTEM DESIGN /000 Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: Date q-7- 02- Inspector T3�.. Q_ f3 other pppfy Number of Bedrooms (or other) 4- /087 Mb /doe% &oCA Fu1eo F -SV3 Ch L vo A C A ,,,_d,.r e, T.,w�- ..� .21i /2eS (orb m rr ` ` O.rt P 3 S pas sx� ��pQy f3� ylpes z �q FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Septic T Septic 1 Septic Tank Access � Absorption Area i Absorption Area Tyl Adequate compliance with County and State regulationstrequirementh t Other Date D''/1 —y Inspector�� Y RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE *CONDITIONS: k 1. All Installation mustcomplywith all requirementsof the Colorado State Board of Health Individual Sewage Disposal Systems Chapter 4 25, Article 10 C.R.S. 1973, Revised 1984. 1 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 1 requirement of the permit and cause for both legal action and revocation of the permit. 3. Any person whoconstructs,alters, or installs an Individual sewagedisposal system Ina mannerwhlch involves&knowing and materiel ;. variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 8 months in )ail or both). k While - APPLICANT Yellow. DEPARTMENT Permit Ne X37 10 } Assessor's Parcel No. 1 This does not constitute e building or use permit. �Phon44a:!�-�C 7 Q_ f3 other pppfy Number of Bedrooms (or other) 4- /087 Mb /doe% &oCA Fu1eo F -SV3 Ch L vo A C A ,,,_d,.r e, T.,w�- ..� .21i /2eS (orb m rr ` ` O.rt P 3 S pas sx� ��pQy f3� ylpes z �q FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Septic T Septic 1 Septic Tank Access � Absorption Area i Absorption Area Tyl Adequate compliance with County and State regulationstrequirementh t Other Date D''/1 —y Inspector�� Y RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE *CONDITIONS: k 1. All Installation mustcomplywith all requirementsof the Colorado State Board of Health Individual Sewage Disposal Systems Chapter 4 25, Article 10 C.R.S. 1973, Revised 1984. 1 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 1 requirement of the permit and cause for both legal action and revocation of the permit. 3. Any person whoconstructs,alters, or installs an Individual sewagedisposal system Ina mannerwhlch involves&knowing and materiel ;. variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 8 months in )ail or both). k While - APPLICANT Yellow. DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER jOOV N ADDRESS CONTRACTOR JJ1 PHONE Goa 5- ADDRESS 5 ya 5 V (^/� 23 S,'/f CG. PHONE _87Go-_S�oi%2_ PERMIT REQUEST FOR (� 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). Near what City of Town 110 /� R I,/ SizeL i Legal Description or Address 1wn .SS AyojP_ /yV 6 � SPC 3 52 WASTES TYPE: � DWELLING Gras sv �1� ( ) TRANSIENT USE BUILDING OR SERVICE Number of Bedrooms ( ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ('Q Garbage Grinder 06 Automatic Washer (X Dishwasher SOURCE AND TYPE OF WATER SUPPLY'QU WELL ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: A114_ DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ICf Was an effort made to connect to the Community System?_ d A site elan 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 to Property Lines: (septic tank &leach field)10 feet YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE_ ISSUED WITHOUT A SITE PLAN. GROUND CONDITIONS: i Depth to first Ground Water Table i 0 Percent Ground Slope_/D TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (� SEPTIC TANK ( ) AERATION PLANT ( ) 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 ( ) EVAPOTRANSPIRATION (x) UNDERGROUND DISPERSAL ( ) ABOVE GROUND DISPERSAL ( ) OTHER - DESCRIBE ( ) SAND FILTER ( ) WASTEWATER POND WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 0 D PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) Minutes per inch in hole No. I Minutes per inch in hole No. 2 Minutes inch in hole NO. 3 Minutes per inch in hole NO. _ Name, address and telephone of RPE who made soil absorption Name, address and telephone of RPE responsible for design of the 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 PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY! 1