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Home My WebLink About03747GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 109 8th Street Suite 303 Glenwood Springs, Colorado 816()1 Phone (303) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Legal Descr1pt1on of Assessor's Parcel No SYSTEM DESIGN ______ Septic Tank Capacity (gallon) ______ Percolation Rate (m1nutes/!nch) ---+----Other Numbe of Bedrooms (or other) _____ _ Permit N: 3 1 4 1 Assessor's Parcel No. This does not constitute a bu1td1ng or use permit. D Reatqeu1red Absorption Area -See Attached lnspectur-:c_ ______ ~--1/,--~--'D'--------------------Special Setback Requirements L , - FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call lor Inspection (24 hours notice) Before Covering Installation Syslem Installer ___________________________________________ _ Septic Tank Capacity __________________________________________ _ Septic Tank Manufacturer or Trade Name ---------------------------------- Septic Tank Access w1th1n 8" of surface Absorption Area--------------- Absorption Area Type and/or Manufacturer or Trade Name--------------------------- Adequate compliance with County and State regulat1ons1requ1remenls ______________________ _ Other ______________________________________________ _ Date ______________ Inspector ______________________________ _ RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE •CONDITIONS: All 1nstallat1on must comply with all requirements of the Colorado State Board al Health lnd1v1dual Sewage Disposal Systems Chapter 25, Article 10 CR S 1973, Revised 1984 2 This perm1t 1s 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 v1olat1on or a requirement of the permtl and cause for both legal action and revocation of the permit. 3 Any person who constructs, alters. or installs an 1nd1v1dual sewage disposal system 1n a manner which involves a knowing and material variation from lhe lerms or spec1f1cat1ons contained 1n the application of permit commits a Class I. Petty Offense ($500.00 fine -6 months 1n JBll or both) White· APPLICANT Yellow -DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER ttf> (, \LilJ~Q.,\ ADDRESS L\ \o \ 4 1 f.\vJ'( (a ~ 0-L\ Q 05 CONTRACTOR ~EL(:.../ ~P,"".E C'-i POo-E" I PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION ~~· -\ 0 c,,z-'-~ . (~PAIR PHONE ----- 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: Size of Lot g.b, CXXJ dJ -t' Near what City of Town ChN'<'oN G.a'\L LegaJDescriptionorAddress ~blL\1 l-\v>i' b t-J-L\ (1u:;rJ~O()() <JRz.I N'-f, WASTES TYPE: f/) DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ()OTHER-DESCRIBE _______________ _ BUILDING OR SERVICE TYPE: r201~1\l\/\L ------------------------- N urn b er of Bedrooms __ L\~ __________ Number of Persons __ y~-- ( ) Garbage Grinder cX Automatic Washer SOURCE AND TYPE OF WATER SUPPLY: (v(WELL If supplied by Community Water, give name of supplier: ( ) Dishwasher ( ) SPRING ( ) STREAM OR CREEK DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_5~-\o __ (Y\_1_L1:._-"l _____ _ Was an effort made to connect to the Community System? --------------- 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: Depth to first Ground Water Table _______________________ _ Percent Ground Slope ___________________________ _ 2 .. TYPf OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED: t:-.j 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: ( ) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRA TION ( ) UNDERGROUND DISPERSAL ( ) SAND FILTER ( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND ( ) OTHER-DESCRIBE WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? !'JD PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer does the Percolation Test) Minutes _____ per inch in hole No. I Minutes ______ per inch in hole No. 3 Minutes per inch in hole No. 2 Minutes er 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 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 anu 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. s;gnoo ~ o"'' Io\ 10\@ PLEASE DAA ACCURATE MAP TO YOUR PROPERTY!l 3 / "-- Designate North Arrow t S\~ti(rJ~ ~oj Your Neighbor's Name & Address ~~ rl1> \~[)fo Your Plot -Shape to Fit (No Scale) r~N '?-.. .. ,aO~ i L\0 / ;-- 16/ .. - Locate well, all streams, irrigation ditchs, and I / y water courses. Draw in your house, septic tank & system, detachetarages, and driveway. If a change of location is necessary, you must submit a corrected drawing, before a '[cate afDccupation will beJ£sued. County Road (\/Ofe the Road Number and Name) -~~~~~~~~~~- enc c l'Y}lwm60\wpdocs\plct loc /~A) ' . \. Your Neighbor's Name & Address