HomeMy WebLinkAbout04116GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name 1/2r C.D. r
System Location
Permit : $,
Assessor's Pa
cel No.
This does not constitute
a building or use,pprmit.„
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Present Address C C. 2_:..,�- Phone r` «� �i�r �, 3 " o:;q
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Legal Description of Assessor's Parcel No
SYSTEM DESIGN
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Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Number of Bedrooms (or other)
•
7i deep
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Inspector._,%7�
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours [yn�otice) Before Covering Installation
System Installer
Septic Tank Capacity
166 (':
h.
Septic Tank Manufacturer or Trade Name tP 01 fsAy.
Septic Tank Access within 8" of surface ! 04)
Absorption Area ..far },��11d Alf) "\,A\ AV!: `1 ( ,"
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements \ 41
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Other
Date
Inspector
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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 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 a violation 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 1, Petty Offense ($500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER moo# q /4 f 4gRAS
ADDRESS
CONTRACTOR
ADDRESS
PHONE
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).
LOCATION OF PROPOSED FACILITY:
Near what City of Town e"(sti.iS Al Size of Lot 34 4.C..
Legal Description or Address 21753/ / 30 o0 25- c:08"
: 02&09 a r3 A
WASTES TYPE: ()() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER — DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms . j1 Number of Persons
(... Garbage Grinder (,� Automatic Washer (--)13"shwasher
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:
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 t /So u_
Percent Ground Slope 20 ft)
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(4) SEPTIC TANK ( ) AERATION PLANT
( ) VAULT PRIVY ( ) COMPOSTING TOILET
( ) PIT PRIVY ( ) INCINERATION TOILET (
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
(rp ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) OTHER -DESCRIBE
VAULT
RECYCLING, POTABLE USE
RECYCLING, OTHER USE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? AZO
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
PLEA
Date l� [� 6-
E
jE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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