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HomeMy WebLinkAboutApplication.pdfGa7-17 eZd County 1 108 8t Street, Suite 401, Glenwood Springs, CO 81601 Ph:970-945-8212 Fx:970-384-3440 Inspection Line:888-868-5306 www.garfield-county.com SEPTIC PERMIT APPLICATION I Perk Fee: ICAO ttly11.20rmffis aMee assessors office 970-945-9134) Lot Size: Lot No: Block No: Subd.JExemption: 2 Job Address: (if an address has not been assigned, please provide CR, HWY or Street Name & City) or and legal description 4 Issue Date: ..9)cl.gol) Owner: (property owner) �'dll - IPd P.4 iota,. a Mailing Address.Ph: P,Lo_ 1' 1 �/ Q` k.,i ��3 -2,po____ Alt Ph: 33-5- 3Q3c 5 Contractor: (54-rGi- cUJ . Oa -way) Mailing Address — Ph:Alt 3 © 5 — 31 -- Ph: ---) .5-(.. - 4)fC5-5.-- 6 Engineer:I Mailing Address Ph: Alt Ph: 7 PERMIT REQUEST FOR: p() New Installation ( ) Alteration ( ) Repair 8 WASTE TYPE: (Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes ( )Other - Describe 9 BUILDING OR SERVICE TYPE: 5� L 4-#4.--f- t.7 1-J t t�� ' Number of bedroohs 'z_ / Garbage Grinder (k)Yes ( )No 10 SOURCE & TYPE OF WATER SUPPLY: If supplied by COMMUNITY WATER, give name ( )WELL SPRING ( )STREAM OR CREEK ( )CISTERN of supplier: / 1 I DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Was an effort made to connect to the Community System? 171e e fc� — %c ill" 1� ' M....;_--, YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth to 1St Ground Water Table Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED: ()�eptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( }Composting Toilet ( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( }Chemical Toilet ( )Other- Describe 14 FINAL DISPOSAL BY: absorption trench, Bed or Pit ( )Underground ( }Wastewater pond ( )Other- Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter Describe 15 Will effluent be discharged directly into waters of the state? ( )YES 41/47110 16 PERCOLATION TEST Name, address & telephone Name, address & telephone RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) Minutes per inch in hole No.1 Minutes per inch in hole No.3 No._ Minutes per inch in hole No.2 Minutes per inch in hole of RPE who made soil absorption test: of RPE responsible for design of the system: 17 Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test 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 falsificati. • or misreprese tatn ma r he denial of the application or revocation of any permit granted based upon said application and legal action for ' •....,0 .s # eta b 3�/�" 2_ OWNERS SIGNATOR , DATE .5- . STAFF USE ONLY Permit Fee: 13 Perk Fee: ICAO Total fees: 1,9: Fees Paid: t—i-3 Balance due: Building Permit: b -5 -D -V1 -►l-3 Septic Permit: + -5-1a-a5r6 Issue Date: ..9)cl.gol) Building & Plan ing Dept: APPROVAL DA E