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GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8"' Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 /Fax: 970-384-3470 I Inspection Line: 970-384-5003
www. ru'fle d-cou
Parcel No: (this Information Is ava~able at Ille assessor1 office 970-945-9134)
Mair· 9 Address I 2 q o{
7 ( ) New lnstanation ~ Alteration ( ) Repa ir ~
~-,--+-=.,...,,.,,==~,..-----...,,.....,.,,---.,,,....----,------:....,.,,,--.,....-..,..,....--------.,....,,.,,._-------,---------------...,....-------------t__i 8 WASTE TYPE: ( )Dwelling ( )Transient Use ()OCommen:ial or industrial ( )Non-Domestic wastes
( )Other -Describe
9 BUILDING OR SERVICE PE :
Number of bedrooi!ls
10 SOURCE & TYPE OF WATE SUPPLY: ( )CISTERN
If supplied by COMMUNITY W TER, give name of supplier:
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YOUR INDIVIDUAL S
12 GROUND CONDITIONS:
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15 ( )YES NO
16 PER CO :rlON TEST RE SUL : (lo be completed by Registered Prtilessional Engineer, if the Engineer does the Pe!Wlati ~
Minutes per inch in hole No.1 Minutes per inch in hole No .3 f<1'
Minutes per inch in hole No.2 Minutes per inch in hole No . t:f 70
Name,addres &telephoneof Ewhomadesollabsorptlontest C< l b~t t.lft.Odj 111-c'.z 2'/A.I. 6-,J--C,, O cJS-C5l
Name, address telephone of PE responsible for design of thesystem: '' " 11 1 1 Ir
17 Applicant ackn es that th completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by
the local health de rtment to 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 pe · is subj to such terms and conditions as deemed necessary to insure compliance with ru les and regulations made, information and
reports submitted here 'th an required to be submitted by the applicant are or will be represented to be true and correct to the best of my knowledge and bel ief
and are designed to be r 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 enial of the application or revocation of any permit g nted based upon said application
and legal action for petjury as provided by law.
OWNERS SIGNATURE DATE
Fma ;cl KKncD ~ncn1p'f1t\S_TAFF USE ONLY
o Permit Fee: Building Permi';J J ~ Total fees: Perk ~ 50-
Septic Permit #: Issue Date:
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LEGEND
E:ic Cas lJne
---Ex Water Une
0 Exbting Well
tr Ex Waler Sbul Ott
lit Ex ll'olcr Spl;ots
$ Ex SepUc Acces3
• Prop Wells lndlY. Lots
0 Prop AbsorpUon Held
Regulski Well #2
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/ A Existing
/ '\._waler line
./ lo Lot 1
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I PO Box 1301 ~ COLORADO f1C1URE ti0.1 1 · Rifle, co s16so '--'--RIVER Well Location Map
II Tcl970-625-4933 ~ENGINEERING
11 fax 970-62?-4564 Civil Engfneering
• Wa11t1 RighU, Augmentation Plan& • Groundwater, war l'e!mitlJllg
•Hydrology, Flood Plaln Anafrs/$ •can~. Pipelines, Dams
Fik Name: Utilitics .dwg Job No; 600 Client:
Dnawn by: BB Aprvd by: CM Date: July S, 2004 Big R