HomeMy WebLinkAbout03858--GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
; ~NDIVIDUAL SEWAGE DISPOSAL PERMIT (o~l i--1 t"'~
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Permit N: 3858
Aseeaaor's Parcel No.
This does not constitute
a building or use permit.
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.-~ PROPER~ _
i Qwner's N:j-(Qnq, J;;emYJ .. \: Present Address~~ Q_p;>3J SJ)l-Phon£-1lo-~$ 7b:
! System Location ,3'250 r:;,Rd--3 7 ~ (o'Cif5'-75?~:j>
Legal Description of Assessor's Parcel No. ___ __,d-o.. ""'-'l~'d-5'--_-__ Ji'--3'----D_O __ -__:l__,,5"-"'~'-------------
! SYSTEM DESIGN
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_.._I ~Q~D~O~-Septic Tank Capacity (gallon) ______ .Other
__ f._Lf _____ Percolation Rate (minutes/inch)
Required Absorption Area -See Attached
Number of Bedrooms (or other) 3
35'-/f ~
'-/-J t/ j; &d Special Setback Requirements:
Date _______________ Inspector _______ ~~-----------------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hou_rs notice) Before Covering Installation
System Installer ________________________________________ _
Septic Tank Capacity /Z:Ji'i:J 1!11*
Septic Tank Manl!.f#cturer or Trade Name _,~,,..,,.-L_L~~'f#.),'-':'-"'~--------------------------
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Adequate compliance with County and State regulationslrequlrements_~,,.="'"-------------------
Other __________________ -f-'---::..-:.---r------------------
•CONDITIONS: r
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems ·.::hapter
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 requiremenf1. Con--
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically beaviole Hon or a
requirement of the permit and cause for both legal action and revocation of the permit.
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' i 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 appl1cation of permit commits a Class I, Petty Offense ($500.00 flne-8
months in jail or bot_h). 1 ~
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White • APPLICANT Yellow -DEPARTMENT i
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER._~,..._..,k~.Q;-"-"'-wGq.q__D~·~·-<f>,L-'--',e~c~c~·~..__~o~r-~lai~s~a'----LA,_,_.Lf/,~,~~~'~c-£:r_, __
ADDRESS h!S7)}, r.5fc'l!!e/-5,)fC08fw2 PHONE '7zo-8'7(,~.?S7k
CONTRACTOR )-¥.. i . 1Q 1J ,' -,. . .,,-_ C.""_, •• ,,_1M='-m,_ue:li~ULLa ... ·a.__ ________ _
ADDRESS2:fi/oihrpu,c.t f-ZJ 4.ietel Co 'i{lbSl>PHONE '7zo-.t2r
PERMIT REQUEST FOR (/J NEW INSTALLATION ( ) ALTERATION ( ) REPL\.IR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, 1abitable
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 ofTown~-=5'-·,__,i /._f,__ __________ ,Size of Lot .::(aa.-rie::,
Legal Description or Address fdu,i + /..arv/ t&w14 as 5cha.k/.e ii-R.:i 072 '7c. I c~~I. 31
WASTES TYPE: ~ DWELLING ( ) TRANSIENT USE S( If
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
BUILDING OR SERVICE TYPE: _ ___.'-=-o"-m'-.e..=--------------------
Number of Bedrooms ---"-''----------N.umber of Persons _ __,,;2."-----
( ) Garbage Grinder ()<)Automatic Washer (~Dishwasher
SOURCEANDTYPEOFWATERSUPPLY: ( )WELL ( )SPRING ( )STREAMORCREEK
If 1. db c . w .. f l" (X.) c.-~+-err'"' supp ie y ornrnumty ater, give name o supp ier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:---''""5'-u...fflu.,_,,./.e""'~;;,_------
Was an effort made to connect to the Community System? --ll-e-~'-------------
A site plan is required to be submitted that indicates the followini: 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 Wll HOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table ________________________ _
Percent Ground Slope ____________________________ _
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TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED:
<K> SEPTIC TANK ( ) AERATION PLANT
( ) VAULT PRIVY ( ) COMPOSTING TOILET
( ) PIT PRIVY ( ) INCINERATION TOILET
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
~ ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) VAULT
( ) RECYCLING, POTABLE USE
( ) RECYCLING, OTHER USE
( ) EVAPOTRANSPIRAT:ON
( ) SAND FILTER
( ) WASTEWATERPONI>
( ) OTHER-DESCRIBE ________________________ _
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_,./}1.,g-='
PERCOLA TION TEST RES UL TS: (To be completed by Registered Professional Engineer, if the Engineei does the
Percolation Test)
Minutes ____ .per inch in hole No. 1 Minutes _____ _,,er inch in hole No. :1
Minutes per 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 systein: ----------
Applicant acknowledges that the completeness of the application is conditional upon such further mand2tory and
additional tests and reports as may be required by the local health department to be made and furnished by the 1pplicant
or by the local health department for purposed of the evaluation of the application; and the issuance of the• Jermit is
subject to such terms and conditions as deeined 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 repre ;ented to
be true and correct to the best of my knowledge and belief and are designed to be relied on by the local depru tment 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~ 1.~ Date 'i)r/oJ'
PLEAS ACCURATE MAP TO YOUR PROPERTY!! 7
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Desi1mate North Arrow
Your Neighbor's
Name & Address
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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 of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name) ~3
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Your Neighbor's
Name & Address
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BOOKCLJFF SURVEY (9701625-2773
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DATE 1/24 /OJ
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BODKCLJFFSURY!'Y SEitVIC!S. lNC.
116 l!:AST TH.llUJ STREtT
IUFLE, COLOR.ADO 11Jfi'41
PH {910) tiZ5-t1JO JOB NO 02057-01
FAX (910} '25-2171