HomeMy WebLinkAbout03869•
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
\ Glenwood Springs, Colorado 81601
\ Phone (303) 945-8212
OSAL tERMI
Owner's Name_~Q'="._R..,u~fY\-+f-tJ-(p"""'-h--'-'-t"l-'-----Present Address 0 3b lf Wleo..J...ow (,If'\• G" · S.
Permit N~ - -~
~~---
This does not constitute
a building or use permit.
Phone
System Location __ ___,tf/if~.._____._Q"'-3...._._{, ..... 8.___,0'JeLL.O=a_J""'-'O"-'W"'-------=ki:LL~· __ f;,,.,_,.__,,S~----'--£_.1._L~~~o-LI ____ _
Legal Description of Assessor's Parcel No. _____ W2sfk==~'-"'=-l'\::..ufs_,,__ _ _,,S=u'-'b::l=c....:•:_ ________________ _
SYSTEM DESIGN
______ Septic Tank Capacity (gallon) ______ Other
______ Percolation Rate (minutes/inch) Number of Bedrooms (or other) ____ _
Required Absorption Area -See Attached
Special Setback Requirements:
Date _____________ Inspector _________________________ ~--
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer ________________________________________ _
Septic Tank Capacity ______________________________________ _
Septic Tank Manufacturer or Trade Name--------------------------------
Septic Tank Access within 8" of surface --------------------------------
Absorption Area----------------------------------------
Absorption Area Type and/or Manufacturer or Trade Name --------------------------
Adequate compliance with County and State regulations/requirements _____________________ _
Other ___________________________________________ _
Date _____________ Inspector ___________________________ _
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
1. All 1nstallat1on 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 fulty 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 I, Petty Offense ($500.00 fine -6
months 1n jail or both).
White. APPLICANT Yellow -DEPARTMENT
i .
Check
Cash
Aaaessor's Parcel No. ---------Permit N: 3 8 b 9
CHARGES
Percolation Test $100.00
(includes final inspection)
Permit Processing Fee $50.00
Owner's Name 0 {( U rA fJ JO h C\
Address at System Location 0 3 b 1' Me t?-J..o w
aid S"D · of> •
I
' '
Lo. G-1.
' "
~'(I~ ,.
Money Order 1
ALL CHECKS ARE TO BE ADE PAYABLE TO GARFIELD COUNTY TREASURER j
:
•
While -APPLICANT
{JJe~11K_,
' Ad J <J"' -fv e yr sfi fl_j
' ' .... c.~-~~-u~/:l..fif.IL I ta ri I 1 ;,fr
Yelow -DEPARTMENT
.. ,,_,'
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
CONTRACTOR. _ __,ttt~.cf."-"-'~'--~11...-..~~ef.<-LL:.~~k~?~l~w~ .... "'-~~~~~~~~~~~
ADDRESS~---¥1/c~~-6~¥'--'~~'~2---g~,/~~tr='~·,~£~""''-----
PERMITREQUESTFOR ( ) NEWINSTALLATION ~TERATION ( )REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water we11s, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
Ne'arwhatCityofTown r4,,,., / ~Ra'¥JC SizeofLot I.Mt
I:ega!DescriptionorAddress o?t:t: ,&f,..,f,.,.J k 14 ,.. G.u'e,. w .. d&y.,t.
WASTES TYPE: (~ DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: __ _.,,$...,JHF-D~W_Q_~[_l\.,,--0)-+-------------
Number of Bedrooms Number of Persons._~-==----
<)Jf Garbage Grinder ( ) Automatic Washer (/()Dishwasher
SOURCEANPTYPEOFWATERSUPPLY: ~WELL ( )SPRING ( )STREAMORCREEK
If supplied by Community Water, give name of supplier: (,.,/ .-$"( fZu.-J::..
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 followini: MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tanlc 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 ___________________________ _
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
~ SEPTIC TANK.kr>rd·"? ( ) AERATION PLANT
( ) VAULT PRIVY ( ) COMPOSTING TOILET
( ) PITPRIVY ( ) INCINERATION TOILET
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
(::I() ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ·) ABOVE GROUND DISPERSAL
( ) VAULT
( ) RECYCLING, POTABLE USE
( ) RECYCLING, OTHER USE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
( ) OTHER-DESCRIBE _ ___.4J,~'if..__..4'"''fL....._./._...,.."'"___.JS""""'t'-'9"'-"<-f,_..·,,:r+-q------------J
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE1 ----
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer.does the
Percolation Test)
Minutes ____ -rper inch in hole No. 1 Minutes ------rer inch in hole No. 3
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 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 ~ Date _ ___,,/t''-1-/'"-"7-:....;Z.~k"'"'l'_S"-----
PLEASE D~TE MAP TO YOUR PROPERTY!! '
•
Designate North Arrow ~
\{\"
Your Neighbor's
Name & Address
Your Plot -Shape to Fi~. ~
(No Scale) ~ '>
~~~·e!J "'' , --
/ -------F~:
;
I \ ( ) / 11
\
--
I
~(
f.'c.1tl
l I
I
-
..\.
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)
cric c \wpw!l\60\wpdocs~
•
l3A)
'
. '·
Your Neighbor's
Name & Address