HomeMy WebLinkAboutApplicationGcz�-fz`eZd Goun
108 e Street, Suite 401, Glenwood Springs, CO 81601
Phv9?0-9.15-5212 Fx..9?0-384-3-140 inspeclion Line:888-868-5306
www.garfield-countv.com
SEPTIC PERMIT APPLICATION
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STAFF USE ONLY
Permit F p.,,
tioil vaNtif fr Ace 970.945.9134)
Lot Size: Lot No: Block No: Subd.lExemption•
Mtn anti. ti ToduP
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Job Address: (flan address has not
OIbeen assigned, please provide CR, NWYor Street Name & War and legal description
4
Building Permit:
Owner. owner)
,k outl. 'I' Ch itE
Mailing Addres
Ph:
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Alt Ph:
tt*Pr
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Date:
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ntractrv.
Mailing Address
Ph:
Alt Ph:
Engineer6 1211 SS13C -
aili rens
= Ph:
Alt Ph:
7
PERMIT REQUEST FOR: ( ) New Installation Alteration ( ) Repair
WASTE TYPE: jIling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( }Other — Describe
9
1
BUILDING OR SERVICE TYPE: . -
Number of bedrooms Garbage Grinder ( )Yes I No
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SOURCE & TYPE OF WATER SUPPLY: {IAMELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier _ -
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DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 10 Ground Water Tabl lat Percent Ground Slope
13
I
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED
ItiSeptic Tank ( }Aeration Plant ( )Vault ( )Vault Privy ( }Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
a Cher- Describe
14
FIAL DISPOSAL BY:
luoTAbsorption trench, Bed or Pit ( }Underground Dispersal
( }Wastewater pond ( }Other- Describe
( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
15
Will effluent be discharged directly into waters of the state? ( )YES (r10
+
PERCOLATION TEST RESULT: (lo be completed by Registered Professional Engineer, it the Engineer does the Percolation Test)
Minutes per inch in hole No.1 Minutes per inch in hole
No.3
No._
II
Minutes per inch in hole No,2 Minutes per inch in hole
Name, address & telephone of RPE who made soil absorption tests
Name, address & telephone 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
the local health department to be made and furnished by the applicant or by the local health department for purposed of the evaluation
issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations
reports submitted herewith and required to be submitted by the applicant are or will be represented to be true and correct to the best
and are designed to be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied
understand that any falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
and I�gai action for pe provided b 1
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
for herein. I further
upon said application
OWNERS SIGNATURE DATE
STAFF USE ONLY
Permit F p.,,
Perk Fee:
nta s:
Fees Pni
Balance due:
Building Permit:
7
Septic Permit:Issue
Date:
--0,/,-d.,
Building & sinning
pt:
�
7 // 20 /2,
APPROVAL .,
..:
DATE
,6