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HomeMy WebLinkAbout02087 lb GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N_ 2 0 8 4 109 8th Street Suite 303 Assessor's Parcel No. e Glenwood Springs, Colorado 81601 Phone (303) 945 -8212 L it This does not constitute 4 INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. PROPERTY / „ ` .. - , i . ..., 4, R Owner's Name Ran Tacker Present Address 3669 100 Rd.. Carbondale phone 963 -3021 I System Location 3669 160 Rd. s Carbondale Legal Description of Assessor's Parcel No. �AV _ i! SYSTEM DESIGN f, /2 > Ll Septic Tank Capacity (gallon) Other 1 li 4 ., �^. 4 d� / A' /t Percolation Rate (minutes /inch) Nu ber of Bedrooms (or other) . ' ' , Required Absorption Area - 9es,4Wshed / p r .C '-- t or. ?71 jot r Al OY$V$t' P'M S' 3 0 / _ s 3 P 34 Special Setback Requirements: ®+" 5 l e 4 q ' C o a t A c t o n S VS t P�ri, - Cf -Cc./J 3 1 S-11-7-3 .COQ. 1 +` Date s Inspector�7 g FINAL SYSTEM INSPECTION AND APPROVAL (as installed) p j Call for Inspection (24 hours notice() Before Covering Installation i f System Installer Atom (om 1 t Septic Tank Capacity 12 - 7 v ' , 7_ /.2'/ ' 7 � "A i !., Septic Tank Manufacturer or Trade Name (+ � ? e r _ /..2 _ C�..? c . tf ', " v I , Septic Tank Access within 8" of surface 4 p 1 Absorption Area 5 i( A 1 4 PO Lv 5 65 `� /14 -+&r" 1 1 hi / 5O -7 2 a- �'R,: �/- I Absorption Area Type and /or Manufacturer or Trade Name Q e 0 "I ! A � 4r Q is '- / `5 0 " 71 `l \ tti Adequate compliance with County and State regulations/requirements_2-r--''''''...- t Other / Q'-? Date rp r 30 -/ 7 Inspector, c re ll i - e/` -4. 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 I 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 ($500.00 fine — 6 months in Jail or both). Applicant: Green Copy Department: Pink Copy 1% Application ~'' INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by County Official: OWNER_ — dD Li (fro : 1 0 0 \DURESS_ j(( 700 /i�* 0,44 44 PHONE `11.3 io 1! 100 :UNTRACTOR _ 5,10, ADDRESS PHONE _ PIIONE , '2 - v I 'ERMIT REQUEST FOR: ( ) New Installation 5 Alteration ( ) Repair ker 4 r'e- \ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable building, location of potable water wells, soil percolation '.est holes, soil profiles in test. holes. (See page 4.) '.00ATION OF PROPOSED FACILITY: County 61,As ik lear what City of Town PAL Y4Yra /c' Lot Size 5( C'7r14; Legal Description IIASTES TYPE: (?() Dwelling ( ) Transient Use ( ) Commercial or Institutional ( ) Non - domestic Wastes ( ) Other - Describe BUILDING OR SERVICE TYPE: (lumber of bedrooms Number of persons S ( ) Garbage grinder (A) Automatic washer (j() Dishwasher SOURCE AND TYPE OF WATER SUPPLY: (X ) well ( ) spring ( ) stream or creek Give depth of all wells within 180 feet of system: /4 If supplied by community water, give name or supplier: GROUND CONDITIONS: Depth to bedrock: — Depth to first Ground Water Table: Percent ground slope: �,/ DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 9 /11,1, s _ Was an effort made to connect to community system? _ TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: ($) Septic Tank ( ) Aeration Plant ( ) Vault ( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use ( ) Pit Privy ( ) Incineration Toilet ( ) Recycling, other use ( ) Chemical Toilet ( ) Other - Describe:_ FINAL DISPOSAL BY: ( >4) Absorption Trench, Bed or Pit ( ) Evapotranspiration ( ) Underground Dispersal ( ) Sand Filter ( ) Above Ground Dispersal ( ) Wastewater Pond ( ) Other - Describe: WILL EFFLUENT BE DISCIIARGED DIRECTLY INTO WATERS OF TIIE STATE?__21/O • • • r , 011. PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.) 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 Mo. lame, address and telephone of RPE who made soil absorption tests: lame, address and telephone of RPE responsible for design of the system: Ipplicant 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 lepartment to be made and furnished by the applicant or by the local health department for 'nrrposes of the evaluation of the application; and the issuance of the pernitt.is subject to .uch terms and conditions as deemed necessary to insure compliance with rules and regulations idopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies that all statements 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 -?f 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 under- stand that any falsification or misrepresentation may result in the denial of the application n• revocation of any permit granted based upon said application and in legal action for per- jury as provided by law. Nate /7 �_ -- — Signed y s PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY • Pane 3 PLOT PLAN AND DESIGN FEATURES: Include by measured distance location of wells, springs, potable water supply lines, cisterns, buildings, property lines, subsoil drains, lake, cater course, stream, dry gulch and show location of proposed system by direction and distance from dwelling or other fixed reference object, and additional submissions in support of this application such as data, plans, specifications, statements and commitments. • Page 4