HomeMy WebLinkAbout02251 lo, t
a y � �
ri . ` QARFIELD COUNTY DO ' , , , I m' N O kNITATION DEPARTMENT Permit N: 22511
109 St)f$', t 'stilts 909 Assessor's Parcel No
° Glenwood ap fli Colors 1 901
Phone 03) 94
h. f .::.,. r -_ .- .... _. _..... .. .' This does not constitute
INDIVIDUAL SE4IAGE DPS
4 000 L PERMIT a building or use permit.
PROPERTY
Ian Colgate' Pre sent Address Phone
West park Dtive G.B. 945 -9448
ss
Owner's Name y Phone
System Location
1St Q.. County Road SOO, Silt
Legal Description of Assailer 's Parpel No
SYSTEM DESION ,, r
/4. ...c" 0 Septic Tank Capacity (gallon) Other 4
( /C, I ' i
' i.,. / ., ' , , ' 'f 'Percolation Rate (minutes/inch) ,Num of B edrooms ( or other) 4 r t !
o' P, A,t, + .PAS r *e r e- is x W o x 3 n at'
Required Absorption Area -See A --- 84 Pr aa;.Jtat at ' c4,
IC.c'��
Special Setback Requirements: y1 ,E - F (, R � L Zo%e O'1/ 3 r V eP'a , A-tiLm-
D 7 ^/' 7 if Inspector __„µ 1b-n t Ll.a -4ns.A
FINAL SYSTEM INSPECTION AND APPROIYAL (s Installep)
p
Call for Inspection (24 hours notice) Before Covering Instnha$i$n,' ‘ r
c,
n,
System li : A faei
C
,'.: Septic Tank Capacity.y. 42 .s.-0 4 o l f
Septic Tank Manufacturer or Trade Name r17�Y ) 0 -2
Septic Tank Access within 8" of sLrface ^";o Yy " ,., , - t
Absorption Area /- (!/1 i S j • "fir 1 / '"" " fi 3 I oratrze Jr
Absorption Area Type and/or Manufacturer or Trade Name J peX,. Itir *r /n _2
Adequate compliance with County and State regulatlon*frequlreme �'"��
Other / �, / / yt 1
Date ! 0 _ `a. 1P -' c7 r� Inspector —. z e',1 _faL� :�"'�J'nh I
RETAIN WITH R ECEIPT 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 permlt Is valid only for connection to etructpres w� 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 ebtion. revocation of the permit.
3. Any person who constructs, alters, or installs an IndlvlI sewage disposal system In a manner which involves a knowing and material
I' variation from the terms or specifications oontalned I n the application of permit commits a Claes I, Petty Offense ($500.00 fine — 6
I . months In Mil or both).
OF, Applicant: Green 9,opy Department: Pink Copy
—
•
Application
INDIVIDTIAi, SEWAGE DISPOSAT, SYSTEM APPT.ICATION Approval By
// ) County Official
ft
OWNER il /-& 4A ,i _
ADDRESS /P /' bar . PHONE 'kite s' yr v 'I!
CONTRACTOR , .. .re t «/' /,_.._ _ '
ADDRESS PHONE
PERMIT REQUEST FOR: 4Q New Installation () Alteration () Repair
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
(See page 4). //
J.00ATION OF PROPOSED PAM 4TY • County �! 'r /g2t
Near what City or Town 'Si// Lot Size ).l10' Ara-6
Legal Description
WASTES TYPE : 94 Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: 4,/xJ41$- Tim/ ay En.t n
Number of bedrooms '`F Number of persons
$ Garbage grinder Y 4 Automatic Washer $ Dishwasher
SOT IRO? AND TYPE OF WATER ST JPPI.Y• 60 well () spring () stream or creek
Give depth of all wells within 180 feet of system: /�h. 'tU 1417_ y r' U�, " T.TIO
If supplied by community water, give name of supplier:
GROTJND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SY TEM:
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:
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? /
SON. PERCOT,ATION TEST RESI If NS; (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. _
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 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 local department of health in evaluating the same for purposes of issuing
the permit applied for herein. 1 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 g fY■ _
Y HA, Signed 1- - $ Q J t/
PI,E,ASE, DR AW AN ACM JR ATE MAP TO YOI JR PROPERTY
#- svm PIA
/I ilV JIIIII
iii ,
/ r]
0
O
.-s.-L-71- 77,;44-( 9 ,'�
etA1 A'n x+51 47. dt1 )
13" 11'` a7
D a -
T. l y 3a
@) J7ct /sir 20
v� 1 " .eat,. I ur .)- k-t,,