HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATION
— 108 8 ' Street, Suite -40i -Glenwood Springs Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
�3n rfield-count
1
Parcel No:this information is available at the assessors off 970-945-9134)
GI -33 1-tC'.s It`++I �a�----i
2
Job Address:4esen addresshas not bt.en assigned, pleise provide Cr, 1 I Street llama
5 C1IJ *.i Fps` -''1i TL
& City) or and legal description
3
Lot Size: Lot o: Block No: Subd./ Exemption:
IC) is
4
Owner: (property owner)
Cu i- s C INS z
Mailing Address
kTA5LD
Ph:
110 - 309 03q
Ph:
9,-io-q -3aza
Alt Ph:
Alt Ph:
5
Cont ctor:
`1Lr Cle A j4,
Mailing Address l
(V. ��`-) Slur
6
Engineer:
ALL Secy c.� Scant_
Mailing Address
p® �g "1 61eNt e
Ph:
(170•-6! e, - $033,
Alt Ph:
7
PERMIT REQUEST FOR: ( ) New Installation ( ) Alteration �r V
8
WASTE TYPE: (- citing ( )Transient Use ( }Commercial or Industrial ( )Non- Domestic wastes
( )Other -Describe
9
BUILDING OR SERVICE TYPE: i e t4 CL:
Number of bedrooms Garbage Grinder„Y ( )No
10
SOURCE & TYPE OF WATER SUPPLY: LL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier: "
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: [Pd,{
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 1s1Ground Water Table 7 Percent Ground Slope of O Ste ► 1-1
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
ptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other- Describe
14
4 FINALISPOSAL BY:
,(]Sarptian trench, Bed or Pit ( )Underground Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
( ) astewater pond ( )Other- Describe
15
Will effluent be discharged directly into waters of the state? ( )YES
16
PERCOLATION TEST RESULT: (lo be completed by Registered Professional Engineer, if the Engineer does the Pe talion Tesil �' j��
Minutes O per inch in hole No.1 Minutes -Z.0 per inch in hole No.3 I : Cti 1 Z..
Minutes 0 per inch in hole No Minutes per inch in hole No._
Name, address & telephone of RPE who made soil absorption test: 1 1 sY C c t2 3 610-60.J
Name, address & telephone of RPE responsible for design of the system: '11 M " " "
17
Applicant acknowledges that the completeness of the application is
the local health department to be made and furnished by the applicant
issuance of the permit is subject to such terms and conditions as
reports submitted herewith and required to be submitted by the applicant
and are designed to be relied on by the local department of health
understand that any falsification or misrepresentation may result in
and legal action for perjury as provided by law.
conditional
deemed
in evaluating
upon such further mandatory and additional test and reports as may be required by
or by the local health department for purposed of the evaluation of the application; and the
necessary to insure compliance with rules and regulations made, information and
are or will be represented to be true and correct to the best of my knowledge and belief
the same for purposes of issuing the permit applied for herein. I further
'al o` the application or revocation of any permit granted based upon said application
OWNERS SIGNATURE
DATE
Permit Fee:
STAFF USE ONLY
Perk Fee:
IA (-I
Total fees:
Septic Permit #:
11-46\
Building Pe(rmmit #:
14)9-1M3
Issue Date:
3-�3-c�O 1D
Building & Planning Dept:
1N °
APPROVAL
�- C
DATE