HomeMy WebLinkAboutApplicationYfi Lc/ Ii
108 8th Street, Suite 401, Glenwood Springs, CO
Ph:970-945-8212 Fx:970-384-3440 Inspection Line:
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SEPTIC PERNIIT APPLICATION
81601
888-868-5306
1
Parcel Nu. (tris inffrrrrafurr is avaltabfe at the assessors office 970-945-9134)
23q3 ;31— 00 -- S99
Lot Size:- Lot No: Block No: Subd.l mpuuon' 1 r
Z.0 Of.(eietiA W S
2
Job Address: (if an address has not been assigned, please ktre CR, HWv or Street Name & City) or and legal desaEplion
[6 19 5 G g . /o(1 C v\. � , Co . q 1(23
4
0 er: (p •pertyowner)
•rer,•)1 . ,
Mailing Address
(6/95 cit /01
Ph:
970,1(03 Y`l2
Alt Ph:
7a 3�Airetito
5
Con actor:Mailing
Sa Vin e—
Address
Ph:
6
•
Engii er Feltz.
1/ ,rviGe {% ;
M �'ling A ress� ,,,,` 4 ,
(vl PY�tuvt
Ph. ,
�'� �,/� Sa. 3
Alt Ph:
7
PERMIT REQUEST FOR: K New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: ')Dwelling
( )Other — Describe
( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
9
BUILDING OR SERVICE TYPE:
Number n{ bedrooms 11 Garbage Grinder Wes ( )No
10
SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
b()WELL ( )SPRING ( }STREAM OR CREEK ( )CISTERN
of supplier
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
7 tin i Ie— S
l v
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1St Ground
e
Water Table / •f Percent Ground Slope < u
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
()Septic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other- Describe
14
FINAL DISPOSAL BY:
())Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( }Other-
Dispersal ( )Above Ground Dispersal ( }Evapotranspiration ( )Sand filler
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES ()ONO
16
PERCOLATION TEST RESULT: (to bemmpletedby
Minutes
Minutes
Name, address & telephone of RPE who
Name, address & telephone of RPE responsible
Registered Professional Engineer, if the Engineer daes the Percolatton Test)
) S per inch in hole No.1 Minutes / S per inch in hole
No.3
No._
' co `f(t, 1 Sys_ 04
1 S' per inch in hole No Minutes per inch in hole
made
fumished
and
be submitted
department
law.
soil absorption test
for design of the
r I f a . 5D1O Gf i 7•
system: ' ..:: • Pe. r /Pi Se - .' _.../
: :..-. • CO.
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
for herein. 1 further
based upon said application
17
Applicant acknowledges that the completeness
the local health department to be made and
issuance of the permit is subject to such terms
reports submitted herewith and required to
and are d: • ed to be relied on by the local
underst at any falsific tion 'srepresentation
and leg -, an orperju as ]'' ided b
Lit")
of 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
may result in the denial of the application or revocation o any pe mit granted
<
OWNERS SIGNATURE DATE
�P l•1•]d�
C'011 -1l -
Permit Fee:
STAFF USE ONLY
Perk Fee:
E-196
fees:
Fees Paid:
-
Building Permit: Septic Permit:
Er- 30Y a-K-1[-ta-a--.00
Bui ding & 1
11' 01':11.
DATE
Issue Date:
Balance due:
is i Sd -
5b3 3