HomeMy WebLinkAboutApplicationcczfze1cd Cou#iy
108 eh Street, Suite 401. Glenwood Springs, CO 81601
Ph:970-915-8212 Fx. 9-0-384-3440 inspection Line:888-868-5306
www.darfield-countv.com
SEPTIC PERMIT APPLICATION
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Parcel No: (this information is avaitabte at the assessors office 970.945.9134)
ICU — 310 3•Cao -_ bCt►4
Lot Size Lot No: Block No: Subd.iExemption:
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Job Address. wan address has not been assigned, please provide CR. HWYor Street Name 8 City} or and legal description
Coq.' In Dia, Co-_.(—� Vi4Aoza ii.h C 1• A latnl t --.0 r tA-'„r
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Owner: (properly owner)
74d-rnerpit Za-Gkee4.
Mailing Address 7.t
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Ph:
Alt Ph
5
Contractor:
Mailing Address Nssirsire Lo
7)1 — 9)556)�$
-Ziver
6
Engineer:
.4u. 4Eav re
Mailing Address azugusol, LoP
? ?.A44 gtGrft-
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Pb:
7e) &l$— 5o33
A 1 Ph. -
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PERMIT REQUEST FOR: New Installation
( ) Alteration
or industrial (
( ) Repair
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WASTE TYPE: j. selling
( )Other — Describe
( )Transient Use ( )Commercial
)Non- Domestic wastes
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BUILDING OR SERVICE TYPE: -. . ,,-_.g
Number of b •;rooms
Garbage Grinder f es ( )No
( }STREAM OR CREEK ( }CISTERN
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SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give
name
SYSTEM:xt:
System?
Ground
SYSTEM
Plant
other
FELL ( }SPRING
of supplier:
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YOUR
DISTANCE TO NEAREST COMMUNITY SEWER
Was an effort made to connect to the Community
INDIVIDUAL SEWAGE DISPOSAL
GROUND CONDITIONS:
Depth to 1st
Pc
rtia __,n,- —
SYSTEM PERMIT WILL NOT
-
Water Table Percent Ground
BE ISSUED WITH OUT A SITE PLAN
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See $rf74t... p
Slope
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TYPE OF INDNIDUAL SEWAGE DISPOSAL
Septic Tank ( )Aeration
( )Recycling, Potable Use ( )Recycling,
10lher- Describe
(ISDS) PROPOSED:
( }Vault ( )Vault Privy ( )Composting Toilet
use ( )Pit Privy ( )Incineration Toilet ( }Chemical Toilet
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FINAL DISPOSAL BY:
( )Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( )other-
Dispersal - .hove Ground Dispersal ( }Evapotranspiration ( )Sand filer
Describe
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Will effluent be discharged directly into
PERCOLATION TEST RESULT: (to be completed
Minutes
Minutes
Name, address & telephone of RPE who
Name, address & telephone of RPE responsible
waters of the state? ( )YES A-1/10
by Registered Professional Engineer, if the Engineer does the
per inch in hole No.1 Minutes
Percolation Test)
per inch in hole
No.3
No._
per inch in hole No,2 Minutes per inch in hole
made soil absorption test:
for design of the system:
_5e_
i4
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Applicant acknowledges that the completeness
the local health department to be made and
issuance of the permit is subject to such terms
reports submitted herewith and required to
and are designed to be relied on by the local
understand that any falsification or misrepresentation
and legal action for perjury as p. d by
of the application is conditional
fumished by the applicant
and conditions as deemed
be submitted by the applicant
department of health in evaluating
r ay result in the
law.
upon such further mandatory
or by the local health department
necessary to insure compliance
are or will be represented to
the same for purposes
denial of the application or revocation
and additional test and
for purposed of the evaluation
with rules and regulations
be true and correct to the best
of issuing the permit applied
of any permit granted based
reports as may be required by
of the application and the
made information and
of my knowledge and bel of
for herein. I further
upon said application
OWNERS SIGNATURE
DATE
Permit Feer
Perk Fee:
STAFF USE ONLY
tal fees:
Acts
Paid: 50
I / ✓ l
Balance due:
Building Permit:
Septic Permit:
to5t,
Issue Date:
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