HomeMy WebLinkAbout03791I
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109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945·8212
lf.IDIVIDUAL SEWAGE DISPOSAL PERMIT
fJIOPERTY
Permit N: 37~1
Aaaeaaor's Parcel No.
This does not constitute
a building or use permit.
'1 ttner's Name Bi I\ me~J' I fte J Present AddressO Cf 8'~ c:~ ~IS SI It c.o~b'.>~e
: System Location 0 '\ ia. C (t )_, \ $ J( I + C,o X' I b S >--
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I J J.egal Description ot Assessor's Parcel No.--------------------------------
L~ llY$TEM DESIGN
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I CV2(2 Septic Tank Capacity (gallon)
1 Percolation Ratelm1nutes/inch)
Required Absorption Area • See Attached
Special Setback Requirements:
Date _ _,'3:....._-_/-'-9_-_D::;_?""/ _____ inspector
_____ _cOther
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed).
Call for Inspection (24 hours notice) Before Covering Installation
Systemlnstaller ~ ~..Ld (O?lJ7-z...e.-...._
Septic Tank Capacity_L/._,,¢,,_,..),,,'---"Z)"'------------------------------
Septic Ta~k Manufacturer or Trade Name ---'~'""'£-.l"'~====='-'-"'Ll ____________________ _
Septic Tank Access within 8" of su~face --'Y'rZ......-=.::._-:;------::=:::;;::::::------------------
Absorption Area Ir QA ~ ~ Pf g=
1/10
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Absorption Area Type and/or Manufacturer or Trade Name ~~""'.µ.'J~f-"4t.-"jL.'.c£=.,,_/.!.t/L<lfuc::· JL.L... _ _:.,_,_:;::_ _______ _
Adequate compliance with County and State regulations/requirements ff~
Other ________________________________________ _
Date_~3_,__-.... J:.../.__-_..O'-.'};J.,.,_ ___ Inspector __..()q..,.i'.f<d(.!'-'ti.<Cr:::I-,. /"1-J1!...L:::.led~~L==-----------
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 System\ 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.
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f 3. Any person who constructs, alters, or installs an Individual sewage disposal system In a manner which Involves a knowing and material f
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). J
'i-White. APPLICANT Yellow. DEPARTMENT ' )
INDIVIDUAL SEW AGE DISPOSAL SYSTEM APPLICATION
OWNER :=te,; 0 8 / 1...>t. llA i; '{ 6 IS.
ADDRESS tPt{B.1 (]," R£ 3' t ~
CONTRACTOR ~ ¢ r AA. G ~ .c...., o
PHONE t:l~-1}('9(
ADDRESS PHONE6 .;;2 S 8713
PERMIT REQUEST FOR (v{ 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 __ &;~/c.::t...=--4.7 ___________ Size of Lot :3 S' t7.C U">
Legal Description or Address ~ .l/fl:l (}, ff?I, .3 IS' S ,, .. "f CO &!65.2
WASTES TYPE: (~DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE ________________ _
BUILDING OR SERVICE TYPE:~3'~~)j',-C~~J-h~o~tt.~'S~€ __ ±_,__~/~d_'14_77._""tf~------
Number of Bedrooms Number of Persons ~ --=----
( ) Garbage Grinder C0Automatic Washer C0Dishwasher
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:_3=--m.,_......._;~(~e~.s. ______ _
Was an effort made to connect to the Community System? ---------------
A si e Ian is re uired to be submitted that indicates the followin
Leach Field to Well:
Septic Tank to Well:
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 _ __."--........ ""-------------------------
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TYPE OF INDIVIDUA.L SEW AGE DISPOSAL SYSTEM PROPOSED:
( vf 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:
(I"} 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? PC
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes er inch in hole No. I -----r Minutes ___ . ___ per inch in hole No. 3
Minutes er 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 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.
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Designate North Arrow
Your Neighbor's
Name & Address
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Your Plot -Shape to Fit ~ ~//
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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)
criee:\~~\plot.loc
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Your Neighbor's
Name & Address
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