HomeMy WebLinkAbout3410 Derby Mesa Loop - 168508100007INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT
Eagle County Department of Environmental Health PERMIT N® 0731
P.O. Box 850 - 550 Broadway
Eagle, Colorado 91611
Telephone: 328-7311 or 949-5257 or 927-3823
YELLOW COPY OF PERMIT MUST PLEASE CALL FOR FINAL INSPECTION BEFORE
BE POSTED AT INSTALLATION SITE COVERING ANY PORTION OF INSTALLED SYSTEM
Owner: Ben R. Wurtsmith Telephone: 691-4360
Address: 3410 Derby Mesa Drive (P.O. Box 21 - Burns, CO)
System Location:- 3410 Derby Mesa Drive
Licensed Installer: Owner License Number:
Conditional installation approval is hereby granted for the following:
Minimum requirements: Gallon Septic Tank or Aerated Treatment unit
Absorption area of dispersal area computed as follows:
Percolation rate: 1 Inch in 5 Minutes
Absorption area per bedroom Sq. Ft.
Number of Bedrooms X Sq. Ft. minimum requirement per bedroom -
equals Total Sq. Ft. minimum requirement
Special Requirements:
Date: Environmental Health Officer:
CONDITIONS:
1. All installations must comply with all requirements of the Eagle County Individual Sewage Disposal System
Regulations, adopted pursuant to authority granted in 25-10-104, C.R.S. 1973, as amended.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building
requirements. Connection to or use with any dwelling or structure not approved by the zoning and building
departments shall automatically be a violation of a requirement of the permit andcause for both legal action and
revocation of the permit.
3. Section III, 3.21 requires any person who constructs, alters or installs an Individual Sewage Disposal System to
be licensed according to the regulations.
FINAL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Eagle County Individual Sewage Disposal System
Regulations until the system is approved prior to covering any portion of the system.
INSTALLED ABSORPTION OR DISPERSAL AREA: SQ. FT.
INSTALLED SEPTIC TANK: GALLONS; DEGREES; FEET
DESIGN ENGINEER OF SYSTEM:
INSTALLER OF SYSTEM:
SEPTIC TANK CLEANOUT TO WITHIN 12"OF FINAL GRADE OR
AERATED ACCESS PORTS ABOVE GRADE:
PHONE:.
YES NO
PROPER MATERIALS AND ASSEMBLY: YES NO
COMPLIANCE WITH PERMIT REQUIREMENTS: YES NO
COMPLIANCE WITH COUNTY / STATE REGULATION REQUIREMENTS: YES NO
(Any item checked NO requires correction before final approval of system is made. Arrange a re -inspection when
work is completed.)
DATE (Final Approval) ENVIRONMENTAL HEALTH OFFICER:
DATE (Re -Inspection) ENVIRONMENTAL HEALTH OFFICER:
RETAIN WITH RECEIPT RECORDS PERMIT
Name of Applicant: Ben R. Wurtsmi th Name of Owner: _Same
Amount Paid;
$200.00 Receipt Number: C Date:
5/25/82
Cashier:
White and Pink Copies - Environmental Health Department Yellow Copy - Applicant / Owner
4 Box CEO w
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PER'IT IEE _ $150 PE=C'CL:%T1T11 TEST FEE = SEO
APPLICATION' FCR iiIDI'� IDU1L S`P—GE DIS:OS:tL SYSTE?' PEP,"IT
NAME -OF OI.INER:
ADD RI•:SS:
NAP;[: OF APPLICANT (IF DIFFERENT FROM M-MER): 440eyft�K&Afthe
ADDRESS: 3
DF.SIGN ENGINEER OF SYSTEM (IF APPLICABLE):
ADDRESS:
9���ri3ll��
PHONE:
PHONE:
PERSON RESPONSIBLE FOR INSTALLATION OF SYSTEi-;'.:
ADDRESS: PHONE:
P-,RNIT APPLICATION IS FOR: (ref` New Installation (' ) Alteration ( ) Repair
LOCATION OF PROPOSED FACILITY: County Lot Size
City or Town, if -within City or To:.m LigitS
LEGAL DESCRIPTION: 13
STREET (RURAL) ADDRESS:
IS SYSTEM! DESIGNED FOR LESS THAN 2,000 GALLONS PER DAY? (!%1 Yes
( ) No
BUILDING OR SERVICE TYPE: (Check applicable category)
(� Residential - Single-family dwelling ( ) Residential - Triplex
( ) Residential - Duplex ( ) Residential - Quadplex
( ) Commercial - State usage
Persons S # Bedrooms 3
WASTE TYPES: (Check all applicable)
( ) Commercial or Institutional (V/ Dwel1ing
( ) Non -domestic wastes ( ) Transient Use
( ) Other
SOURCE AND TYPE OF WATER SUPPLY: ( ) Well (� Spring
Give depth of all wells within 200 feet of the system:
If supplied.,by community water, give name of supplier:
:.T`iPE OF INDIVIDUAL SEWAGE biSPOSA.L SYSTEk PROPOSED:
}'
Septic Tank ( ) Aeration Plant ( )
i .aul. lY•IV� .( ') �.:j�i..i�l,itlJ iV i i:.,6
P( •�
( ) Pit Privy ( ) Incineration Toilet ( )
( ) Greywater ( ) Other
( ) Garbage Grinder
Dishwasher
Automatic Masher
( ) Creek or Stream
Chemical Toilet
Recycling, Other Use
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ( ) Yes (1--7— No
Signature Date., l
INFORMIATION BELO'.! TO BE FILLED OUT BY EN1VIR(I IIIENTAL HEALTH OFFICER '
GROUND CONDITIONS: Percent around Slope:
Depth to Bedrock (per 8' Profile Hole): Depth to Groun.i:jater Table:
SOIL PERCOLATION TEST RESULTS: P'.inutes per inch in Hole Ilo. 1
Minutes per inch in Hole No. 2
!?inutes per inch in Hole No. 3
FINAL DISPOS^,L oY: ( ) Absorption Trench, Bed or Pit ( ) Eva.potr nspiration
( ) Above Ground Dispersal ( ) Sand Filter
( ) Un�4_erground Dispersal ( ) lWastel:iater Pond
( ) 0 t"_- r
PERCOLATION TEST FEE: S50
I.S.D.S. APP.
OWNER: P6,0 W 09-T5"04
LEGAL DESCRIPTION:
RURAL ADDRESS: t_cop
TYPE OF D4ELLING: # OF BEDROOMS:
DATE OF PERCOLATION TEST: Sir jV3 TYPE OF SOIL:
TEST HOLES PRESOAKED? Yes )— No
TIME
WATER DEPTH
INCHES OF FALL
RATE
1
2
3
1
2
3
1
2
3
1
2
3
iG
t
t�L9f
I
f 'YA
PERCOLATION RATE: ____5 TT -
RECOMMENDED MINIMUM SEPTIC TANK SIZE: too �,4
RECOMMENDED MINIMUM LEACH FIELD SIZE:
RECOMMENDED MINIMUM SQUARE FOOTAGE PER BEDROOM:
Site has been reviewed and tested r per ton t
Date Enviroh*lental I e cer *d.
COMMENTS:
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EAGLE COUNTY
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Eagle County OWTS Systems Cleaners Reporting Form
NOTE: Required to be submitted to Environmental Health within 10 days of cleanine an OWTS system
Systems Cleaner Company ' F rr� L Z4L License Number L/ � go
Email Address Y//rycGdG>Sp,� JC_��/jZur! r �6�'yt Phone '7 764 4 �1
Service Technician Jet, Phone
Tax Parcel# —00-607 ,Aiddressof Service rb Z-
Person Requesting Service fear 7'� Phone q ?0 ✓ J
Property Owner. 5 111� -.T2(% Phone �17e-6 5_3 ! :3�
Septic System Permit Number fl t I Tank Size %0-00
Date of service Tank Material 4_0/7 Cne
Sewage Disposal Site
General Condition and Functionality of the System t,
Recommended Repairs _N
Site sketch showing location of the septic tank access lids measured from at least 2 fixed points
(Photos Encouraged)
Signe Date �� ��' 04
S C
(q69 P10
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JOB NAME lAt' G e S- O 6 (- n O - 00 joB o�
JOB FOLDER Product.278 nE ® NEW ENGLAND BUSINESS SERVICE, INC.. GROTON, MA 01471 Printed in U.SA
JOB FOLDER