HomeMy WebLinkAbout02454 ler 1 • GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N _ 2 4 5 a t.. 109 8th Street Suite 303 Assessor's Parcel No. + i Glenwood Springs, Colorado 81601 ' ( Phone (303) 945 -8212 This does not constitute to k ' INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t t PROPERTY p i p t 3 Owner's Name William M Park Present Address 1962 132Rd. Glenwood Phone 945 -8766 1 System Location 004/ County Road 127, Glenwood Springs 1 6 1 Legal Description of Assessor's Parcel No. i 6 SYSTEM DESIGN b (. q • 11 i1› Septic L Tank Capacity (gallon) • Other /. A_ir___iy - 9 i i _ y P Rate (minutes /inch) of Bedrooms (or other) /� / � �, �/ I S. Required Absorption Area - See Attached �/ ✓� i L"V 21 : 2 ox ;• ( �/( 1 J) � lc) II 7- /-/4 y c 2 . 4^ ' Ey { / R' X / fr X 1_2 t.- - )- _7 Special Setback Requirements: 1 !� f Date ' Q � 'S.- 8 Inspector z‹ 4 I FINAL SYSTEM INSP &CtION AND APPROVAL (as install- 'r"; (C.;..1- , °; ' .': ,. Call for Inspection (24 hours notice) Before Covering Installation Pi, System Installer_ aJ. in. Peal& 4' Septic Tank Capacity /00 0 Septic Tank Manufacturer or Trade Name 7- C U. T A /r, l Septic Tank Access within 8" of surface ei-S i c v Absorption Area 13 ' )(I$ ) /v Q i i :, Absorption Area Type and /or Manufacturer or Trade Name }[ i • Adequate compliance with County and State regulations /requirements 44S 4 Other b t Date V 4 ' Inspector 4-1../ 1.. _,- •,. RETAIN WITH RECEIPT RECORDS AT CO STRUCTION SITE A f *CONDITIONS: 1. All installation must comply with all requirements of theColorado State Board of Health Individual Sewage Disposal Systems Chapter t ilt 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- i iii 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. • • t, 3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and materi h } al variation from the terms or specifications contained in the application of permit commits a Class I. Petty Offense ($500.00 fine —6 tl'.` it months in jail Or both). • 1 � Applicant: Green Copy Department: Pink Copy h t . ___ sd - — 1 . JNDIVIDUAI. SEWAGE SEWAGE DISPOSADISPOSAL SYSTEM APPi.ICATION OWNER ADDRESS IQ(o•2 -W Gan,,,Arookzeia Coo PHONE c t`45 531 bb Nn 614S (C' S Pates er. CONTRACTOR t w • .L- . ADDRESS On 2 — (COO tea _ ►.,, , , Sp t^1 PHONE c45 5300 PERMIT REQUEST FOR 44 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 FACILITY: COUNTY Coq„ Q jo2a ` Near what City or Town 0,1/40o,•„ ,.ree. - Q GpIrtel or Lot Legal Description Tov.ma.: ( Soak.Ra..tiie.' S Wes#. ntekke. k"' P GGethto1, a4 wesk ya kke,ekku2es* Yq Qpini WASTES TYPE: 04 Dwelling () Transient Use ( ) Commercial or Industrial ( ) Non - domestic Wastes ( ) Other - Describe BUILDING OR SERVICE TYPE: Number of bedrooms: -3 Number of persons a) Garbage Grinder (x) Automatic Washer (4 Dishwasher SOURCE AND TYPE OF WATER SI 'PM .Y: QQ WELL () SPRING () STREAM OR CREEK Give depth of all wells within 180 feet of system: %\wnL. If supplied by communtiy water, give name of supplier: GROIJND CONDITIONS: Depth to bedrock: Depth to first Ground Water Table: - Percent Ground Slope: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: flares) Was an effort made to connect to community system? f® TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: Qd 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: QQ 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? '00 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 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 appliction is conditional upon such further mandatory d and additional tests and reports as may be required by the local health department to be made and fa d the by the applicant or by the local health department for purposes of the evaluation of the application; issuance of the permit is subject to such terms and conditions as deemed necessary to inusre compliance with rules and regula adopted ts make, information O and reports submitted bmi 1973, ed here ith and required to be submitted ' certifies that all sn , 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 bre relied on by the local department of health in evluating the same fro purposes of issuing the permit of th e a fpr ca t io n. I n or revocation of any understand perm t granted falsification based upon said application and in legal the denial of the applicaio revca action for perjury as provided by law. Signed ..... AM-- c il le Date S tS S • • L 't•' t .. 13 a0 TA , k v II, kg_ ,c,_ 0 ,-, .- _ _,,..„--. 4c, N gas,,,,, ,. ,.... � ��..r --�.f " sw s 3X c o . e4w. 0 e Q�. PERCOLATION TEST RESIITTS: (To be completed by Registered Professional Engineer) 1 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 appliction 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 inusre compliance with rules and regulations adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro 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 Cas/Q.kavv. \N cR Date S I «1 - in EASE DRAW AN ACCT IRATE MAP TO YOUR PROPERTY 13 RCS TA s e k V , j � � > Qet pa SQy,.,an T —- L.e�c._ e-`c' Cl 1,04 -52. d 6er4- c T. rN.__ __ a i swws. ccA. rQc. w. 0 ^ �� —_. tor- \vewGa w pi.lT PI AN AND DESIGN FRATI IR ES Include by measured distance location of wells, springs, potable water supply lines, cisterns, buildings, property lines, subsoil drains, lake, water 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. CRS Via,; ,,v, ,k at w . , 00-113::1/40, 3 0 iscidD,cibser til/+ ceake 08 0- attr - kJU,vu -, Juksitaa cortzczjecalops„ C see CX.aastri broc) - e ISa© ea..nC kerizmi 1. ,Ob' Jr� roc er}i i... nt. To lea,Gle n " r,AA re" 0 4l (P° 1 's j Ps\ S .0 t-zc w ew a�l