HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8'h Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www .earf ietd-countv.com
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Parcel No: (this information is available al the assessors office 970.9459134)
Z--Vl k 2 -SIC o o 'Ism 11
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Job Address: Iif an address has not been assigned, please provide Cr, Hwy or Street Name & Ciry) or and legal descrtpion
3"7-, 3 Crre # ' r pr CFr-l0r,3CA. C Cd TS- 1LOZ3
3
Lot Size: Lot X�pp Block No: Subd.I Exemption:
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Owner. (property owner)
C C)qa t-- V rD ti:
Mailing Address
'333 CraSir-'o ...+
Ph:
et"? 0 UP l 53,k -k7_6
Alt Ph:
5
Contractor.
Mailing Address
Ph:
_
Alt Ph:
6
Engineer._
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MailingAddress 1�
‘51-131hc� PJ L1.—w.�oc1
rPh: 1
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Alt Ph:
7
PERMIT REQUEST FOR: (bQ New Installation ( ) Alteration ( ) Repair
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WASTE TYPE: {welling ( }Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other - Describe
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BUILDING OR SERVICE TYPE: ("Z c. K c1 c J.i- c..i
Number of bedrooms
Lk
Garbage Grinder (74,)Yes ( )No
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SOURCE & TYPE OF WATER SUPPLY: (.)WELL ( )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?
P IF r
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
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GROUND CONDITIONS:
Depth to 1' Ground Water Table Percent Ground Slope
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1808) PROPOSED:
{'<)Septic Tank ( )Aeration Plant { )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recyding, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( }Other- Describe
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FINAL DISPOSAL BY:
((}Absorption trench, Bed or Pit { }Underground
( )Wastewater pond ( )Other
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
-Describe
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Will effluent be discharged directly Into waters of the state? ( )YES (A)NO
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PERCOLATION TEST 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.
1(S ° -.S '1Q'd 8
Minutes per inch in hole No.2 Minutes per inch in hole
Name, address & telephone of RPE who made soil
Name, address & telephone of RPE responsible
absorption test: 1+? (o e o 4c c .-, S ra Z 0 C i S'-1
for design of the system: \-', <.A. Cu ,..-'`.-tiF p r cl i $ t'1 gt gtCe- P, c11/41/4S t31, i 1,
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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. 1 further
understand that any falsification or misreprese ay result in the denial of the application or revocation of any permit granted based upon said application
and legal action for perjury as provided by 1 .�
OWNERS SIGNATURE 6 DATE
P re mitFee:
STAFF USE ONLY
Perk Fee:
Total fees:
3-13
Building Permit fl:
)1-A 53
Septic Permit #:
PA- -- -10 -- 3-A5cA
Issue Date:
Building & Planning Dept:
d/7////,
671/%d
APPROVAL
BATE