HomeMy WebLinkAbout02767 •
( " 2767 .
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. .
PROPERTY ae
' Keith Raines 94028 Hwy 325, Rifle 984 -2372
Owner's Name Present Address Phone_
System Location 0 3 3 3 County Road 337, Parachute •
• Legal Description of Assessor's Parcel No.
(LOCK - CEO G61 Flt 2
SYSTEM DEIGN 1 M F t L - 1 ft A T 0 n S C.& . (3n C o ro N II 07 rr 4 u1 X10 OiFrti3C 34 it II
. -71 • i 0 Septic Tank Capacity (gallon) \ Other
' re q Mri 3 L1 2 f r ereS
t J Percolation Rate (minutes /inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements: •
•
Date 1 4' '97 Inspector A /'
o
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ,
Call for Inspection (24 hours notice) Before Covering Installation
System Installer 0 w S- ,$ I E
Septic Tank Capacity 12_ 0 'nJ
Septic Tank Manufacturer or Trade Name S, / CV I' n J c ' v T i Pr Co ,
A.
Septic Tank Access wi ^ f surface — O K ' - Af G C 0 5 C 0 C ( 44 S 1----- Absorption Area ` 4 1 m r/ ( r r' /I ` A T O K s � bat Fr a
t
Absorption Area Type and /or Manufacturer or Trade Name 1 t ( /! C "T/t A r on .
Adequate compliance with County and State regulations/requirements
Other .
C. •
Date ` 1 6 1 - ? Inspector ' 4■
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS: i
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Swage 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 tequirementti. Con-
, nection to or use with any dwelling or structures not approved by the Building and Z9ning off ice shall aptomatically be a violation or
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 (5500.00 fine — 8
months In jail or both).
While - APPLICANT Yellow - DEPARTMENT
- // // INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER /`'// °( 0A6
A6 s% RUB ��'_S c//
ADDRESS 9g � / 11 < 11w}� 32C �.0274_ % PHONE 6250 /5' 4m 907 -2372
CONTRACTOR 4 /
/�
ADDRESS sot ore / t2e /i—er/ /Z/ C U PHONE 6 Z5 b / fa
PERMIT REQUEST FOR 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).
LOCATION OF PROPOSED FACIL,ITY: q
Near what City of Town AM rA / nee— / Size of Lot 7. 8 / cic rc
/� 5
Legal Description or Address 1. fl A� /� 6"- C 7 1/ Ed 33 7
WASTES TYPE: 04 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: ,4e Sie e/-27 o/
Number of Bedrooms .3 Number of Persons 3
( ) Garbage Grinder (a Automatic Washer (A Dishwasher
SOURCE AND TYPE OF WATER SI IPPLY )Q WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System? A / A✓.. /te-A (rare /)
A site plan is required to be submitted that indicates the following MINIMIJM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
WITHOUT A SITE PLAN.
GRO! IND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
•
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(X) 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:
(C) 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
PERCOLATION TEST REST 11.TS (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
Minutes per inch in hole No. I 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 purposed 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
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.
Signed /�u��! Date / — d
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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