HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8th Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
wwv, .garfield-county.cam
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Parcel No: (this Information is available at the assessors office 970-945-9134) 2 I �D L 7 , 0 0 /
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Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
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Lot Size: Lot No: 1 Block No: Subd./ Exemption
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Owner: (property owner) /41/(bee i
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Mailing Address 1. --Cf-
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071/Y x:1/131 b.-
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Alt Ph:
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Contractor:
Noy hes C7ceAcat = ,-15
Mailing Address q
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PE MIT REQUEST FOR: i ( ) New Installation (k) Alteration ( ) Repair
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WASTE TYPE: ()Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other — Describe
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BUILDING OR SERVICE TYPE: t a 6 i
Number of bedrooms Garbage Grinder (X)Yes ( )No
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SOURCE & TYPE OF WATER SUPPLY: (X)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?
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YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
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GROUND CONDITIONS:/
to 1a Ground Water Table [2 ‘..4.7 ` Percent Ground Slope 3 Y ,_z 7-
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM
V)Septic Tank ( }Aeration Plant
( )Recycling, Potable Use ( )Recycling, other
( )Other- Describe
FINAL DISPOSAL BY:
(>4)Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( )Other-
(ISDS) PROPOSED:
( )Vault ( )Vault Privy
use ( )Pit Privy ( )Incineration Toilet
( )Composting Toilet
( )Chemical Toilet
( )Evapotranspiration ( )Sand filter
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__
Dispersal ( )Above Ground Dispersal
Describe
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Will effluent be discharged directly into waters of the state? ( )YES (. NO
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PERCOLATION TEST RESULT: (to be completed rsteradProfessional Engineer, ifthe Engineer does the Pereol tIon Test)
Minutes per inch in hole No.1 Minutes / per inch in hole
No.3
No,_
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
Applicant acknowledges that the completeness of
the local health department to be made and furnished
issuance of the permit is subject to such terms and
reports submitted herewith and required to be submitted
and are designed to be relied on by the local department
understand that any falsification or misrepresentation
and legal actin for pe 'ury as pro' ed by
absorption test:
for design of the system: _ S e tI.i 1=.Iv 1., e n,. -e, c e c 5:4,4 y%.,1-►
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the application is conditional upon such further mandatory and additional test and
by the applicant or by the local health department for purposed of the evaluation
conditions as deemed necessary to insure compliance with rules and regulations
by the applicant are or will be represented to be true and correct to the best
of health in evaluating the same for purposes of issuing the permit applied for
may result in the denial of the application or revocation of any permit granted based
�t
reportg as may be required by
of the application; and the
made, information and
of my knowledge and belief
herein. 1 further
upon said application
OWNEpc)fAT RE DATE
Permit Fee:
-73
STAFF USE ONLY
Perk Fee:
Totaf
Septic Permit #:
Building Permit #:
NSA
Issue Date: . tCh 1
1Z-3-08
Building & PI ing Dept:
APPROVAL
DATE