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
www. garfiie l d- ca u nry. com
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Perk Fee:
Parcel No: (this information is available at the assessors office 970-945-9134) 2 15 zz2 03
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Septic Permit #:
1
Job Address: (if an address has not been assigned, please rovide Cruor Street Name & City) or and legal dear
157 OfI�6(e51 ti S
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Mailing Addressre�
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Subd.I Exemption:0
Ph:
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Alt Ph:
379-W
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W Owner: ( operty owner)
C her t ANS
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Mailing Ad res t
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Alt Ph:
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Mailing Address
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Alt Ph:
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PERMIT REQUEST FOR: ( ) New Installation ration ( ) Repair
WASTE
TYPE: ling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
)Other - Describe
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BUILDING
OR SERVICE TYPE:
Numberedrooms
Garbage Grinder es ( )No
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SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
E L ( ) PRIN
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of supplier. d: 4 :JI ` 'Co-
N/Pt
()STRF�41y1 OR CREEK ( )CISTERN
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1
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
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GROUND CONDITIONS:
Depth to 1st Ground Water Table Percent Ground Slope
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TYP 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
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FINAL DISPOSAL BY:
( )Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond ( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration and filter
Describe
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Will effluent be discharged directly into waters of the state? ( )YES ( )NO
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PERCOLATION
Name,
Name,
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.
Minutes per inch in hole No.2 Minutes per inch in hole
address & telephone of RPE who made soil
address & telephone of RPE responsible
absorption test:
for design of the system:
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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 - +. is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations
reports su• itted her wil a . - ' •'red to be submitted by the applicant are or will be represented to be true and correct to the best
and a - • 'gned to - . / ed on by e local department of health in evaluating the same for purposes of issuing the permit applied for
und. •�. at an 4.ication •• •• ' a•res- - !o may result in the denial of the application or revocation of any permit granted based
an, leg- ofioL'vid .y . 9.—/—° 7
Or
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
herein. I further
upon said application
0 ERS SI OAT r -i DATE
4- G.'.0
STAFF USE ONLY
Permit Fee:
157.°°
Perk Fee:
Total fees:
,c10
Building Permit #:
t 1522—
Septic Permit #:
1
Issue Date:
9, / e07f
Buildin: • Planning
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APPROV r ,r DATE