HomeMy WebLinkAboutOriginal OWTS Docsi 1t3a .°
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i GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N 3 ? U 1, t1
t 109 8th Street Suite 303 Assessor's Parcel No.s ,
1 t ,Glenwood Springs, Colorado 81801 a
Phone (303) 945-8212 6•
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This does not constitute
3 ) INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
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1 I llL i F ' Present Address I lit art1 Phon I `ti r ,r Owner's Name
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1 { System Location N.I
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i ) Legal Description of As essor's Parcel No.9
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P } SYSTEM DESI
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t 9 o Septic Tank Capacity (gallon)Other 11 tAi
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d Percolation Rate (minutes/inch) Number of Bedrooms (or other)i
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i"Required Absorption Area: See Attached
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t. f Special Setback Requirements:
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Date
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
a re Coverin Installationf ' CII for Inspection (24 hours notice) Befog
C +'System Installer e(I,.; S Ir e' Cf 1/, r4 F/e e vu / S0 r
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G /Septic Tank Capacity 00 C h'2 i' r
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Septic Tank Manufacturer or Trade Name Eel fF L.- A/ / i
If i -Septic Tank Access within 8" of surface r.
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Absorption Area Q or. i r r ( 7Sot/ 4 t he
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Absorption Area Type and /or M anufacturer or Trade Name J•' / 1" / . 7 .. R470 / R.
7 Adequate compliance with County and State regulations /requirements 0 t)
o Other ,t "'
Date - . ,J /Z,>" /q 1 Inspector
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RETAIN` WITH RECEIPT RECORDS AT CONSTRUCTION SITE le a •
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- S
J nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a
i •requirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs,or installs an individual gpilsewage disposal system Ina manner which involves a knowing and material
ti variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense (5500.00 fine — 8 4I^ i •
k n / jonths In Jail or both).p ','
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f 1/4 White - APPLICANT Yellow- DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 9X13 ER F ¥/C t= ti d ±oe L C
ADDRESS 2 iv. 2 Nb/'L 72 >f6G7Ci, R/6 PHONE q91)--6 n
CONTRACTOR .t/. C iv i5 C T C4 V N7/
ADDRESS 33 i' J? D 3 /L T g 2 PHONE 71 2 3 oJ'
PERMIT REQUEST FOR f )<TEW 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 S «- T Size of Lot dig. 65 /9 Ca,
Legal Description or Address
WASTES TYPE:DWELLING TRANSIENT USE
COMMERCIAL OR INDUSTRIAL NON - DOMESTIC WASTES
OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms Number of Persons
Garbage Grinder Automatic Washer Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: DWELL SPRING STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 3 /7 / -
Was an effort made to connect to the Community System?N O
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 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
2
TYPE IVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SERTIC TANK AERATION PLANT VAULT
VAULT PRIVY COMPOSTING TOILET RECYCLING, POTABLE USE
PIT PRIVY INCINERATION TOILET RECYCLING, OTHER USE
CHEMICAL TOILET OTHER - DESCRIBE
FIN DISPOSAL BY:
VI ABSORPTION TRENCH, BED OR PIT EVAPOTRANSPIRATION
UNDERGROUND DISPERSAL SAND FILTER
ABOVE GROUND DISPERSAL WASTEWATER POND
OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?MO
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 I Date 7/7/,
PLEASE DRAW AN ACCUI&TE MAP TO YOUR PROPERTY!!
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