HomeMy WebLinkAboutApplication- PermitI
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name
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System Location S i `�'� ‘ wog iii.96
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r' Parcel No k /�� le � CP
Legal Description of Assessor's �� �C.a(.
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SYSTEM DESIGN 2.,, 4 c A (11 - C '`( A 044A a E2 — Q E.°
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I Q Q d 396ptic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other) 3
4 --br s
ent Address[
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Permit N- 3 0 1 q
Assessor's Parcel No.
This does not constitute
a building or use permit.
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Required Absorption Area - See Attached
Special Setback Requirements:
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Date ! '^ —
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Cali for Inspection (24 hours notice) Before Covering Installation
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System Installer mu't'e R
Inspector if
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•- Septic Tank Capacity /4:96:)e)
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Septic Tank Manufacturer or Trade Name 1 L P41)/&)d
Septic Tank Access within 8" of surface
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Absorption Area 49/4 Pas • 1 FI Thg-4
Absorption Area Type and/or Manufacturer or Trade Name ‘f -r1414 11t%I L r1 T i*. cp-'
Adequate compliance with County and State regulations/requirements Vas
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Other
Date / %
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9 7 4 Ins 442"fri./(L,fr-7Z-1-pector
RETAIN WITH RECEIPT RECORDS AT CONSTRION SITE
4 ,t *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 o 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
irariation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine —8
months in Jail or both).
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While - APPLICANT Yellow - DEPARTMENT
Aug -14-98 08:12A Stella Archuleta 970-945-7785 P_02
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER D CaXcMO
ADDRESS E CC dc' R - PHONE )0 95 —(95-00
CONTRACTOR COUC
ADDRESS 5"0 CQ 4ov PHONE gq 57 5
PERMIT REQUEST FOR KNEW INSTALLATION
( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FASzaTY
Near what City of Town 1 I + Size of Lot q • q 5—LO
Legal Description or Address 5o l N a Ctf car?
WASTES TYPE: (DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms
( ) Garbage Grinder
Number of Persons LP
(V Automatic Washer (V Dishwasher
SO 1RCE AND TYPE OF WATER SUPPLY: (p4 WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was'an effort made to connect to the Community System?
l7 � 1.11 I
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Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE IS$L.ED
WITHOUT A SITE PLAN,
OROUND CONDITIONS:
Depth to first Ground Water Table UD5
Percent Ground Slope
N1
2
Aug -14-98 08:12A Stella Archuleta 970-945--7785 P.03
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
AERATION PLANT
COMPOSTING TOILET
INCINERATION TOILET
OTHER - DESCRIBE
VAULT
RECYCLING, POTABLE USE
RECYCLING, OTHER USE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) OTHER - DESCRIBE
EVAPOTRANSPIRATION
SAND FILTER
WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE
PERCOLATION TEST RESULT& (To be completed by Registered Professio
the Percolation Test)
Minutes per inch in hole No. 1 Minutes
Minutes per inch in hole No. 2 Minutes
STATE?
nal Engineer,
no
if the Engineer does
per inch in hole NO. 3
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 , .r4 1 /ga1,
Date U r )q
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3
Aug -14-98 08:13A Stella Archuleta
County Road (Note the Road Number and Name)
970-945-7785 P.04
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