HomeMy WebLinkAboutApplication - Permitêf'-¡'u 5ä. ôb
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
Permit 4460
Assessor's Parcel No.
This does not constitute
a building or us€ permit.INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Lar &Present Address &LtÕ cRtrlc'Jq.te 8l fff" 9Yf-fæs
K4c¡ CR*t\ à-Ca-r bo*c$stQ @Eltx:
System Location
9.3- ) 3l-ss -3-13Legal Description of Assessor's Parcel
SYSTEM DESIGN
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch)
-Other
Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements:
Date- lnsPector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for lnspection (24 hours notice) Before Covering lnstallation
System lnstaller-
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Absorption Area
Septic Tank Access within 8" of surface
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requi
lnspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
Other
Date
*CONDITIONS:
1. All installationmustcomplywithall requirementsoftheColoradoStateBoardofHealthlndividual SewageDisposal SystemsChapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. Th¡s pêrmit is valid only for connection to structures which have f ully complied w¡th County zoning and building requirements. Con'
nection to or use with ány dwelling or structures not approved by the Building and Zoning off ice shall automatically be a violation or a
requirement of the permit and cause for both legal action and revocation of the permit.
3. Anypersonwhoconstructs,alters,orinstallsanindividual seWagedisposal system¡namannerwhichinvolvesaknow-ingandmaterial
variát¡on from the terms or specif ¡cations contained ¡n the application of permit commits a Class l, Petty Offense ($500.00 f ine - 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMÊNT
GARFIELD COLINTY SEPTIC PERMIT APPLICATION
108 8th Sheet, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-38 4-3470 / Inspection Line: 970-384-5003
2
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parcer No: (this iräarryqa'.q.j'S$f ,jWgry 3
' öii':i':j'$.i;K'.i\)ere&citv)o'an ëÄääSi" ÐAuË co g ILz3
, Lot No:4 .o3 A.-<*¿¿--
Block No:Lot Size:Subd./ Exemption:
Job Address: (if an address has not been
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qlbfi{,-xpjPh AIt Ph:
3ftlq ۧqo cQ. rrMailing Address4Owner: (property owner)
BøBB\ ¿u¡ rurÑóf-)Afl
Ph:AIt PhMailing Address5Contractor;
,- ctlo (o/8-þÐ AIt PhMailinq Address lo Ée,'( ZbrlV2ÉÉl+- 6ç¡rurûb Ls (t 6
6 Enoineel.- se,u-r,"s sop¡c
7 ( ) New lnstallation ( ) Alteration (tJ,RÉþairPERMIT REQUEST FORI
8 ffietting ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastæ
( )Other -
BUILDING OR SERVICE
Garbage Grinder ( )NoNumberof
9
t0 (Lì¡úELL ( )SpRrNG ( )STREAM 0R CREEK ( )CTSTERN
lf supplied by COMMUNITY WATER, give name of
SOURCE & TYPE OF WATER SUPPLY:
1l
Was an effort made to connec-t to the Community System?
DISTANCE TO NEAREST COMMUNITY SEWER
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
t2 ø'dIvGROUND CONDITIONS:
Percent GroundDepth to l"tGround Water
l3 TYPE OF INDIVIDUAL
ñà6it¡ctant
(
(
Potable Use
SEWAGE DTSPOSAL SYSTEM (ISDS) PROPOSED:
( )Vault Privy( )lncineration Toilet
( )Composting Toilet
( )ChemicalToilet
( )Aeration Plant
( )Recycling, other use
( )Vault( )Pit Privy
t4 FINALÐISPOSAL BY:
¡.fOsorption trench, Bed or Pit
( )Wastewater pond
( )Underground Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
I )Other- Describe
l5 Will effluent be discharged direc{ly into waters of the state? ( )YES ( $}+et-
16 PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineêr does the Percolation Test)
Minutes-perinchinholeNo'2Minutes-perinchinholeNo.-.^r l¡
Name, address & telephone of RPE responsible for design of the system:
Name, address & telephone of RPE who made soil absorption
per inch in hole No,1 Minutes- per inch in hole No.3
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional tæt and reports as may
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 lerms 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 conect to the best of my knowledge and belief
be required by
of health the same for purposes of issuing the permit applied for herein. I furtherand are designed to be relied on by the local
theu or revocation of any permit granted based upon said applicationunderstand that any falsifìcation
bvland legal action for perjury
3T*t"l
DATEOWNERS SIGNATURE
17
T.A.F'F
Total fees:Building Permit #:5o - .,ì)
Permit Fee:Perk Fee:
A.)/4.
Issue Date:
61, rluk+qâoSepticPermit #:
Building & Planning Dept:
APPROVÄL DATE