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HomeMy WebLinkAboutpitkin.eh.272929201088 (2017)Pitkin County Environmental Health Department Onsite Wastewater Treatment System (OWTS) USE PERMIT APPLICATION 76 Service Center Rd ' Aspen, CO 81611 Website: www.aspenpitkin.com/ehnr/ Anrnlic-atinn fnr r_nntinnne4 I lcm of nrn Cv:cl:r.r. rmAmo Parcel ID# (available from the Pitkin County Assessor's Office 970-920-5160 or at www.pitkinassessor.org): % / Purpose of Use Permit: Contact/Applicant Mailing Address: ity, St Zip: PROPERTY TRANSACnON ❑ REMODEL/ADDMON Property Address: 7 9,r Cell Phone: rw Lot: BloI Fi g: Su ivision: 1 Residences: Other # of Bedrooms: fixtures/uses: Property Owner(s)': \ Email Address: t yyt Owner's Mailing Address: G `� , S te, Zip: Home Phone: 11J Business Phone: 'Contact information must be provided for the owner signing this application Primary Contact Person/Ap li a t if not owner): L Contact/Applicant Mailing Address: ity, St Zip: Cell Phone: Business one: r. Fax Number: Email Address: Indicate Preferred Method of PermitReceipt: mail Fax ❑ US Mail Licensed Systems I pe to : Ph ne Number: all Address: Fax N tuber: �o' - c S Mailing Address: 4 % rn cf.,o .... PLEASE READ BEFORE SIGNING: I certify that the above Information is complete and accurate and that 1 have provided complete and accurate information In all of the documents Included in my application package. I acknowledge that this department may revoke any permit I am Issued If my application Is found to contain any inaccurate, false, or misleading Information. Please allow 3-5 business days fkProcJssing of Use Permits. FOR OFFICE USE ONLY Received by EH Staff: Fee & Receipt #: Date: T KIN Pitkin County Environmental Health Department Onsite Wastewater Treatment System (OWTS) ' USE PERMIT CHECKLIST GU,� Permit for Continued Use of an Existing OWTS tt r a1 -6405 Case reek Roa , ui a Aspen, CO • 81611 Phone: 970.920.5070 Fax: 970.920.5077 Website: www.aspenpitkin.com/ehnr Some items listed on this checklist may already exist in the Department files. Please contact this department to collect any necessary documentation, using the parcel ID# to identify the property, prior to scheduling an OWTS Use Permit inspection and/or submitting the OWTS Use Permit application packet. A complete application package must be presented at the time of your pre -application conference for acceptance. To schedule a pre -application conference, please call (970) 920- 5070. PLEASE INITIAL EACH ITEM TO INDICATE COMPLETION Only one copy of each item is necessary. Electronic versions of any or all of the documents identified below may be emailed to ehnr(cDco.pitkin.co.us before the date of the pre -application conference�- OWTS Use Permit Application (completed) Site Plan (11x17) Should include general location of each OWTS, buildings, water courses, domestic water source(s), and other pertinent information. Building Floor Plans (11x17) ❑ Current floor plans for a property transaction; or ❑ Proposed floor plans for an addition/remodel that does not increase potential bedroom count or water usage of the structure served by the existing OWTS. Inspection report by a Licensed Systems Inspector A list of Licensed Systems Inspectors can be found at www.aspenpitkin.com/ehnr fAn inspection report is good for one year. Applicable Fee OWTS Use Permit: $100 Please make checks payable to Pitkin County Environmental Health Department. 4fx N ln�' ,, Owner's Name: Address: Parcel Number: Inspection Date: Inspector's Name: Business Name: Phone Number Email: Onsite Wastewater Treatment Systems (OWTS) Use Permit Inspection Form Pitkin County Environmental Health Department 76 Service Center Rd, Aspen, CO 81611 Phone: 970-920-5070 fax: 970-920-5374 Website: I httplIpitkincounty comt248/Wastewater-Treatment Inspection form for continued use of an existing OWTS Jose & Rhonda Lopez 372 Crystal Park Dr Redstone CO 2729 292 01 088 8/15/17 Jason Daubs Altitude Se tic LLC 970 471-1330 laltitudeseptic@gmaii.com Pitkin County Systems Inspector license Number: 119 A copy of this inspection report will be remitted to Pitkin County Environmental Health Department by the licensed Svstems Inspector within 60 days of the inspection regardless of whether the system asses or afls. QUESTIONS FOR PROPERTY OWNER PRIOR TO INSPECTION: Is the home currently occupied? ❑YES [ENO If NO, how long has the home been vacant? How many bedrooms are in the home? 3 If secondary treatment is used, who is the maintenance provider? L_ RECORDS: Were system records available from Pitkin County? YES �NO If YES: Permit number:I Date of Final Approval: # of bedrooms permitted: C� Was an as -built drawing available? ® YES Q NO Is the as -built drawing accurate? ©YES ®NO If NO: Complete a drawing of the system on last page of this form as accurately as possible. Any question marked FAIL will require correction before an OWTS Use permit is issued. SITE CONDITIONS: Proper grading, no evidence of erosion? Improper vegetative cover? Evidence of compaction such as heavy machinery or livestock? Improper discharges such as straight pipes? Evidence of high ground water? Snow cover present? PASS FAIL NO YES NO YES �' PASS ©FAIL NO M YES NO DYES Page 1 Effective Date 111212017 TANK: Tank 1 Tank 2 Tank 3 Tank capacity Tank material 1,000 gallons Concrete gallons gallons # of compartments 2 Date of last pumping Lids/risers in good condition Pass Select One Select One Risers to grade Yes Select One Select One Riser height 24" Riser condition/watertightness Good inlet sanitary T/baffle Pass Select One Select One Outlet sanitary T/baffle Pass Select One Select One Effluent filter (if part of design) N/A Select One Select One Condition of tank material Pass Select One Select One Tank was pumped for inspection Yes Select One Select One If YES, list the pumping company Altitude Septic If NO, when was the last pumping Scum level (1st compartment) inches inches inches Sludge level (1st compartment) inches inches inches Scum level (2nd compartment) inches inches inches Sludge level (2nd compartment) inches inches inches Backflow (if pumped) Pass Select One Select One Midtank baffle Pass Select One Select One Watertightness Pass Select One Select One PUMPS/DOSING SIPHONS: Is a pump or dosing siphon present? YES ' NO If YES, is the pump/dosing siphon functioning properly? ®PASS FAIL Does the pump/wiring/dosing siphon appear to be in good condition? ®PASS ❑FAIL Is the high water alarm working, both visible and audible? DPASS FAIL SECONDARY TREATMENT: Is a secondary treatment unit present? MYESNO ®UNKNOWN If YES, does the unit appear to be in good working condition? YES NO DoesDoes the owner have a current maintenance contract for the unit? HYES NO OUNKNOWN Maintenance Provider: Phone: If there is no maintenance contract, a contract must be in place prior to occupancy of the home. A copy of the contract must be submitted to Pitkin County Environmental Health Department. ABSORBTION AREA: Effluent surfacing? Evidence of past surfacing? Surface dampness? Excessive odors? Field location verified by observation ports or probing Liquid in observation port? If YES, record depth: Distribution Box or ADV part of original design? If YES, is it accessible from grade? Is it level and in good condition? NO NO NO 'orts NO YES YES )ASS Page 2 FAIL YES YES YES Probing YES inches NO NO FAIL UNKNOWN Effective Date 1112(2017 3lease list any recommendations for the continued use of the system: Were any repairs done as a result of this inspection? ONO [—] YES To the best of my knowledge and training, the information collected in this inspection is accurate as of August 15 —�, 2d17 Licensed Systems Inspector Signature: ,� Dau6d Additlnnal Nntpq- 0 �NSaf C'C'X:oN E[] �a Clearly label any pictures and attach them to this form. Print Form Page 3 Effective Date 1112/2017 I�� ���� 3 �a Crys1� awk,1�.-� -��.1,���,\ Altitude Septic, LLC PO Box 1534 Eagle, CO 81631 970-471-0913 AttitudeSeptic@gmail.com AltitudeSeptic.com INVOICE Date Invoice # 8/14/2017 1396 372 Crystal Park Dr. Due Date Due upon receipt Quantity Description Unit Price Amount 1 Inspection 400.00 400.00 1,000 Dump Fee 0.20 200.00 1,000 Pump Fee 0.24 240.00 2 Lids 30.00 60.00 1 Installation, delivery, and disposal of lids 150.00 150.00 Any balance not paid in 30 days will incur a 3% interest charge. Total $1,050.00 Payments/Credits $0.00 Balance Due $1,050.00