HomeMy WebLinkAboutApplication.pdf108 8th Street, Suite 401, Glenwood Springs, CO 81601 Ph:970-945-8212 Fx:970-384-3440 Inspection Line: 888-868-5306 www.garfield-county .com SEPTIC PERMIT APPLICATION J 1 Perk Fee: Fl\1 a. Parcel No: (this information is available at the assessors office 970-945-9134) Lot Size: Lot No: Block No: Subd./Exemption: 2 — 7 .,Dc, Jop Address: (if an address has not been assigned, please provide CR, HWY or Street Name & Cary) or anQlegal description ///(o CA , /3z aGeN41a0P s R/At S LQD 2/k © ( 4er. Issue Date: 47.111 ropertyo n r) vrie Mailing Address V DATE Alt Ph: 5 Contractor: �� c � Mailing Addre � .4h "/ 9/7/5-2 5,.2 Alt Ph: 6 Engineer: ,�747L ( 0 M 'lin Address Ph� y �� 6 9 Alt Ph: 7 PERMIT REQUEST FOR: New Installation ( ) Alteration ( ) Repair ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes 8 WASTE TYPE: (Dwelling ( )Other — Describe 9 BUILDING OR SERVICE TYPE: Number of bedrooms .3 Garbage Grinder ( es ( )No 10 SOURCE & TYPE OF WATER SUPPLY: If supplied by COMMUNITY WATER, give name ( )WELL RING ( )STREAM OR CREEK ( )CISTERN of supplier: 11 DISTANCE TO NEAREST COMMUNITY SEWER Was an effort made to connect to the Community System? SYSTEM: l j /j�(��5 _ �j�% IVL' GulA/ / ! © �dJ YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth to 1,1Ground Water Table Percent Ground Slope 13 TY f 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 FINS DISPOSAL BY: Absorption trench, Bed or Pit ( )Underground ( )Wastewater pond ( )Other- Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter Describe 15 Will effluent be discharged directly into waters of the state? ( )YES ( )NO 16 PERCOLATION 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 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 per it is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and reports sue • ed ierewith 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 . i ed , b; r: e' on by the local department of health in evaluating the same for purposes of issuing the permit applied for herein. I further unde !an. f at :n. /:l•'r,.tio or misrepresentation may result in the denial of the application or revocation any perm't granted based upon said application and g ; '„ fr, , ) .' a p Fp 9 1 a,, 0 ' ERS SIGNATURE DAT Permit Fee: Abi 3 ' Clb Perk Fee: Fl\1 a. Total fees:Fees Paid: Balance due: CP — 7 .,Dc, Building Permit: 451_12 -6 -3 -Il- 33 Septic Permit: 4c3EPir 7-002. Issue Date: 47.111 Buil ' Planning Dept: ti a 1-1 1 21,2()11 V DATE