HomeMy WebLinkAboutApplication-Permit.pdfGarfield County Building & Planning Department 108 8th Street Suite 401 Glenwood Springs, CO 81601~ Phone: (970)945·8212 Fax: (970)384·3470 Project Address Parcel No. Subdivision CR315
Rifle, CO 81650-Owner Information Address Shideler land and cattle company Ll9667 CR 315 , Rifle CO 81650 Contractor(s) Phone Primary Contractor Jonathan Todd (970)984-3553 Ves Proposed
Construction I Details ISDS for single family dwelling Valuation: Total Sq Feet: FEES DUE FEES PAID Amount: Percolation Test Septic Fee· New Total: $100.00 $73.00 $173.00 Inv # SEPT-9-09-19735
$ 173.00 Credit Card Tuesday, October 27, 2009 Section Township Range Phone Cell 9708762757 $ 0.00 o $173.00 $ 0.00 Required Inspections: Fo"",pootlo05 e,'" 1 (970)384-5003 Inspection
IVR See Permit Record Building Department Copy 2
I "If' vJiJl.( ~ ~ ~1?-~ GARFIELD COUNTY SEPTIC PERMIT APPLICATION ~ "b""6 3 S Ct-CAJ1.<1 1088'" Street, Suite 401, Glenwood Springs, Co 81601 ~ ~ ~ Phone: 970-945-82121 Fax: 970-384-3470
1 Inspection Line: 970-384-5003 WWW.5Zafri'l e I(I¥ coun\v,com Parce! No: (this informatio~ available at the assessors office 970.945-3;_ L<:. ~r' s...<--\-\~I'\ 3 \ \? "->1'\5"-1 <>.,
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<-Gvg/c"SO 3 W~ 3~~ -~ Subd.l Exemption: ~ ."<CI~ +~ , 4 Owner: (property owner) Mailing Address Ph: All Ph: ::,~ Se\-;\,,"-r Zbf;7 (t. 31':) 9,~\<... C,,013,(p '-,'57 11'1'70. [.,,\3
-1"2,,,g 5 Contractor: b--\ Mailing Address Ph: All Ph: .:::5"'C)",-~ \0 c; 3 LI'{ ~"c.,,,',",,.:\ Dr. r\.(-V l",,~ "-'l70 -qe« -3')') 3-'001-10,-,\':) -c:.,' '-\ 6 Engine~: G 'i '.
""-<":> Maili~ Address /2.. \'<, Ph: All Ph: v.Jeb 6.r <lLI" W'.IIAvL CO. 170. (n" 1.'-1 « 7 PERMIT REQUEST FOR: K) New Installation ( ) Alteration ( ) Repair 8 WASTE TYPE: (><'jDwelling
( )Transient Use ( )Commercial or industrial ( )Non-Domestic wastes ( )Other Describe 9 BUILDING OR SERVICE TYPE: 5; ""' v Dt, """'\:'" Number of bedrooms ~ Garbage Grinder f()Yes (
)No 10 SOURCE & TYPE OF WATER SUPPLY: ,)XJWELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN If supplied by COMMUNITY WATER, give name of supplier: 11 DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
\«' , <" Was an effort made to connect to the Community System? AI", YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth
to 1" Ground Water Table Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1505) PROPOSED: ( )Septic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Other-Describe ( )Recycling, other use ( )PitPrivy ( )Incineration Toilet ( )Chemical Toilet 14 FINAL DISPOSAL BY: ( )Absorptioo trench, Bed or Pit ( )Underground
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter ( )Wastewater pond ( )Other-Describe 15 Will effluent be discharged directly into waters of the state? ( )YES
( )NO t6 PERCOLATION TeST RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the PercolaUon Test) Minutes per inch in hole No,1 Minutes per inch in hole
No,3 Minutes per inch in hole No,2 Minutes per inch in hole No,_ Name, address & telephone of RPE who made soil absorption test: Name, address & telephone of RPE responsible for design
of the system: 17 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, I further understand that any falsification or misrepresentation may 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 law, .Iv. ~:/h-<V?ftf' OWNERS SIGNATURE DATE STAFF USE ONLY Permit Fee: Perk Fee: Total
fees: Building Permit #: ~ It~\) ( 03 .0\) -\~DO Septic Permit #: Issue Date: "'5'(; P+--Q -()q-'~'5q B~an~: • ~-~~ <1/{r/o'l APPROVAL DATE
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