HomeMy WebLinkAbout02246 .`1..,, IN ' 5.
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N` 2 2 4 6 1
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. 109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (909) 945 -8212
This does not constitute I
INDIVIDUAL SEWAGE DISPQSAL PERMIT a building or use permit. } p
PROPERTY
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Owner's Name Joan & Naryann'-Sabriaki3 Ad rasa 19218 Highway 82, Carbonda 963 -1600
System Location 0133 Kings Rdv Avenue, Kings Row, Lot 24, Carbondale
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN )
1) 1) Septic Tank Capacity (gallon) Other
I/ b,1 1
/ c , , . . n � ' c v Percolation Rate (minutes/inch) Number of Bedrooms (or other) 3 , l'`' t -, � , `e /
4 rG7 Per + J.� a o I
Required Absorption Area - See Attached • /' I ,�
• .j M PI'S' fl 3 '7 A e.ci;,
Special Setback Requirements: A P. . J S 4)'f'40
Date 7 Zr - ?V/ Inspector C ?°`fi7 a1Aen <
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ,.
-Call for Inspection (24 hours notice) Before Covering Installation
System Installer s O di 4.27 -51 deft
Septic Tank Capacity / cd
Septic Tank Manufacturer or Trade Name na 0,L 6.(
Septic Tank Access within 8" of surface . pi
Absorption Area µ� a 1
Absorption Area Type and /or Manufacturer or Trade Name �b 3 N AF -#P
Adequate compliance with County and State regulations /requirements t?:
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Other � i r
.. Date �� . 919. Inspector / 7" ••( //' i � ��
RETAIN WITH RECEIPT RECORDS AT CONS SITE i
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*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 i
variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine — 6 g
months in Jail or both). 3
Applicant: Green Copy Department: Pink Copy
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Application
INDIVID1JAI. SEWAGE DISPOSAL. SYSTEM APP..ICATION Approval By
��jj- County Official
OWNER d01 4 vi4A- RN, iJ 2 +2 rc l�
ADDRESS 40 ( 1- OE _ M'M f CO 1 l PHONE 31 4 163 toe 15 0
'ONTRACTOR ))Jl A ti (re=Y! .
ADDRESS T Pt1/4 -t_.T • PHONE
ERMIT REQUEST FOR: ("New Installation () Alteration () Repair
.ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
abitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
See page 4).
.00ATION OF PROPOSED FACILITY : County CMYC rte.«
Tear what City or Town Boca A aMIeh - Lot Size a • i pcc-ti* •
.egal Description c 2 o •
VASTES TYPE : (445—welling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
() Other - Describe
WUILDING OR SERVICE TYPE:
lumber of bedrooms 3 Number of persons. a •
) Garbage grinder ( ) Automatic Washer ()— I5ishwasher
;Oi IRCE AND TYPE OF WATER SI JPPI.Y: (•) well ( ) spring ( ) stream or creek
live depth of all wells within 180 feet of system:
f supplied by community water, give name of supplier: Wt. T V Wert L. 1 fr. ;ROI
;ROUND CONDITIONS; U
)epth to bedrock:,
)epth to first Ground Water Table:
'ercent ground slope:
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
JJas an effort made to connect to community system?
TYPE OF DIVIDUAL 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 9I3POSAL BY:
(PI 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? /Lib
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OII. PERCOLATION TEST R EST II ,TS: 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 No.
fame, address and telephone of RPE who made soil absorption tests;
lame, 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 purposes 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 adopted 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 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.
Date 4 + ' y- Signed
PLEASE DRAW AN ACCURATE MAP TO YOIJR PROPERTY
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