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HomeMy WebLinkAbout02369 •* e. wuwlw�nl ►R3MVrAaea+�TrTwaw°"s "'� mgr .....,+.. . m,e..ys.�v.+. .. �Y 1. i ' j GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit Ni 2 3 6 9 s 's Parcel No. 109 8th Street Suite 303 Assessor t Glenwood Springs, Colorado 81601 Phone (303) 945-8212 ti ' This does not constitute f (; INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. iy 1 PROPERT7 1 Shawn C. McElroy B.O. Box 822, Rifle, CO 625 -5702 t # ' , I Owner's Name Present Address Phone_ t / County Road 233, Antlers Orchard, Lot 37, Silt ? System location ) / / 9 i ( Legal Description of Assessor's Parcel No. ! f. '' i / C . /,t. - Ft /', r7r µy,_ , ry e r( it C... ( ' SYSTEM DESIGN ee � 4-2141- {i - - -, ' i -...c.: - ; ,\ , A h+ ^ 1 , n1 j FJ iJ '/ ` Septic Tank Capacity (gallon) 1, Ot e �+ * ' 4I - J -46 41 4 ° I - 1 /. Anst - 2- /` Percolation Rate (minGfts /i ibh) IJumber of Bedrooms (or other) .f — n e C r Required Absorption Area - SesAtteolied• / �', ,l Ir / +( - ii 5 Special Setback R� ) I ` - `�'�') Date / ,7.-, ,/ �. Inspector '"fit .� /:aK ii ..`-'dpi ` t1 O 1 , I1 r le t FINAL SYSTEM INSPECTION AND APPROVAL (as installed) r Call for Inspection (24 hours notice) Before Covering Installation x t. System Installer_ a. V I! <. e Q1112 • e �1Ol�l 2 9 } 1 / 2 S� Septic Tank Capacity r Septic Tank Manufacturer or Trade Name Septic Tank Access within 8" of surface . G ,, E / a f 6' !1-0^^'''1 7 Absorption Area eb y 1 / r i r Absorption Area' Type and /or Manufacturer or Trade Name e , Adequate compliance with County and State regulations/requirements �, ii 1 ii 14 7 • Other �` Vim/ 'I Date y -1 / 9e^ �' Inspector �� F RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE {. *CONDITIONS: ff 1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter ' b 25, Article 10 C.R.S. 1973, Revised 1984. 2. This perntjt is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- f nection to or use filth ally dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a t 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 q ' variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine —6 d $ months in jail or both). Applicant: Green Copy Department: Pink Copy i' Application INDJVIDIJAI. SEWAGF. DISPOSAT. SYSTEM APPLICATION A County pproval O ffi By cial OWNER S1-1AO+ C McE Lko • ' ADDRESS Pc BOK 8a1. gAc Co ghGS>J PHONE42S -57bZ Jay /5O, ONTRACTOR � 016 fycAonrion)s 12:cK QG10 I ADDRESS PHONE - Z'7 ERMIT REQUEST FOR: 40 New Installation () Alteration () Repair :teach separate sheets or report showing entire area with respect to surrounding areas, topography of area, =bitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes See page 4). r . £)CATION OF PROPOSFJ) FACILITY : County GAa(yek) dear what City or Town 1R, Fie. Lot Size 10 AL t .ega1 Description SEC 3s TowasL.;p S Soot -t. R4sual r a W es +- 4 i-� 01% A M. Mkt.Y ,No. o,.) Auf1&>s arJ-a4 1>j. Plat. !ASTF „S TYPE : 00 Dwelling ( ) Transient Use ( ) Commercial or Institutional ( ) Non - domestic Wastes () Other - Describe lUILDING OR SERVICE TYPE: dumber of bedrooms, ,3 Number of persons 5 Garbage grinder 04 Automatic Washer (4 Dishwasher OURCE AND TYPE OF WATER SIIPPLY: 00 well () spring () stream or creek 3ive depth of all wells within 180 feet of system: Deo' f supplied by community water, give name of supplier: k/A 3ROUND CONDITIONS: 3epth to bedrock: i lepth to first Ground Water Table: 'ercent ground slope: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:—.S.1J Was an effort made to connect to community system? Nn TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: OQ 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: ()t) 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? No , . ;OiT, PERCOLATION TEST REST JT.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. _ game, 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 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. < 1 1 Date N �� V1 S 4 Signed `,Lo- CW Pr SASE DR AW AN ACCT IRATE MAP TO YOi JR PROPERTY b.11Lee oecfeo Deo. P Ia 1 ; 36 ( 35 • pp r T Y <fr e1 ye t Ro nt 33 so 4-4 4-- IM. 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