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HomeMy WebLinkAboutApplication- PermitGARFIELD 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 k i (C r W 1 i 11:11\/l System Location Permit Assessor's Parcel No. Chisa does not constitute building or use permit. Present Address Phone) Legal Description of Assessor's Parcel No 2 Zi 3 0(1 SYSTEM DESIGN ,f Septic Tank Capacity (gallon) Other ,� —_ Percolation Rate (minutes/inch) Number of Bedrooms (or other) -) f" .e,C -'/ `,,' f7 ~ .g Required Absorption Area - See Attached 5-6 7.4 9 e- 'c 1 -ed `�p , s •J. Special Setback Requirements: •- f t Ll / _—r �'1' •;,; LJ"=-aAr_dc5" `` 3J /G -/G- us Inspector ;'• 77J Date 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 1 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 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 I, Petty Offense ($500.00 fine — 6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT GARFIELD COUNTY SEPTIC PERMIT APPLICATION 108 8th Street, Suite 401, Glenwood Springs, Co 81601 Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003 arfieId-coun.tv.curn t 1 Parcel No: (this information is available at the assessors office 970-945-9134) GP a©© q Zr- 2 Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description (01,i 02 /al 3/3 /14) rite IA t^, 3 Block No: Ll euP � Exemption: f . e SkkiOGQ . � ie;v. p fi - 6 Lot S ,)-c75 Lot No: *1r 2_ C1 4 • Owner: (property Lill 1 owner) i.a4 ?,Ce--- Mailing Address 'eO aC)zseZ Mailing Address Ph: y7e)37T-41'1oC, Alt Ph: 2G -A9' -ft LY 5 Contractor: 0 cam) fry Ph: Alt Ph: 6 Engineer: Mailing Address Ph: Alt Ph: 7 PERMIT REQUEST FOR: ()'f New Installation ( ) Alteration ( ) Repair 8 WASTE BUILDING TYPE: Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes ( )Other — Describe OR SERVICE TYPE: 5 9 (R Number o bedrooms 3 Garbage Grinder ( )Yes ( )No 10 SOURCE & TYPE OF WATER SUPPLY: If supplied by COMMUNITY WATER, give name (XWELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN of supplier: 11 DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Was an effort made to connect to the Community System? !M iJe S YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth to 1s1Ground Water Table Lt Arta ata___ Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED: )Septic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet ( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet ( )Other- Describe 14 FINAL DISPOSAL BY: )Absorption trench, Bed or Pit ( )Underground ( )Wastewater pond ( )Other- Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter Describe 15 Will effluent be discharged directly into waters of the state? ( )YES XN0 16 PERCOLATION Name, address Name, address Applicant the local issuance reports submitted and are understand and legal OWNERS TEST RESULT: (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 No._ Minutes per inch in hole No.2 Minutes per inch in hole & telephone of RPE who made soil & telephone of RPE responsible absorption test: for design of the system: - 17 acknowledges that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by 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 of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and 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 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 that any falsification or misrepresentation ma esult in the denial of the application or revocation of any permit granted based upon said application action for perjury,as provided_ by I ... P 7" '7-c43IF SIGNATURE DATE Permit Fee: r13 STAFF USE ONLY Perk Fee: / .CO Total fees: Septic Permit #: 414 1 - Building & Planning Dept: Issue Date: Building Permit #: APPROVAL DATE