HomeMy WebLinkAboutApplicationGay- eld G'GP
108 8th Street, Suite 401, Glenwood Springs, CO 81601
Ph:970-9.15-8212 F.r:970-384-3440 Inspection Line: 888-868-5306
tivwwv.r:arf field-county.com
SEPTIC PERMIT APPLICATION
1 EIVP1)
APR 19 2012
GARFIELD COUNTY
BUILDING & PLANNING
1
Parcel No: (this information is available at the assessors office 970.945.9134)
2I 73)6 € 000l1
Lot Size: Lot No: Block No: Subd./Exemption:
2
Job Address: (if an address has not been assigned, please provide CR, HWYorStreet Name & City) or and legal description
533$ CI 3o9 p/cteicffu TE
4
Building Permit:
Owner. (property owner)
KuL---es-r--xt71PoPERrex
Contractor:
Ku+ s f Col 5-ttzu rr Ont.!
Mailing Address
Po 150K /S3c�IFri�
Mailing Address
Ph:
4,)0-645-9,210
Ph:
Alt Ph
cl70-6rP -Is is
Alt Ph
5
Date: D
6
•
11—/9- /2—
Engineer.
Mailing Address
Ph:
Alt Ph
7
DATE
PERMIT REQUEST FOR: '() New Installation rcputcF en 577 4.4 ( ) Alteration ( ) Repair
S
WASTE TYPE: pC)Dwell ng ( }Transient Use ( }Commercial or industrial ( )Non- Domestic wastes
( }Other -Describe
9
BUILDING OR SERVICE TYPE: _
Number of bedrooms f Garbage Grinder ( )Yes ( }No
I 0
SOURCE & TYPE OF WATER SUPPLY: (X)WELL ( }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?
5 -1 M i L.
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS: !�
Depth to 14 Ground Water Table Percent Ground Slope-0-K;
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
(:)Septic Tank ( }Aeration Plant ( )Vault ( }Vault Privy ( )Composting Toilet
( )Recyding, Potable Use ( )Recyding, 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 filter
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES (KNO
16
PERCOLATION TEST RESULT: (lo be completed by Registered Professional Engineerif 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 soli absorption test
Name, address & telephone of RPE responsible for design of the system:
17
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 here and requi to be submitted
and are designed ' - r- ed on b e local department
understand th. .ny fa ' icatio . misrepresentation
and legal ac''n f - ' • :,. p •vided by law.
the application is conditional
by the applicant
conditions as deemed
by the applicant
of health in
may result in the
upon such further mandatory and additional test and
or by the local health department for purposed of the evaluation
necessary to insure compliance with rules and regulations
are or will be represented to be true and correct to the best
evaluating the same for purposes of issuing the permit applied
denial of the application or revocation of any permit granted based
9
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
for herein I further
upon said application
OWN '' SIGNATURE
DATE
t~1 .
c� t0 1 �3 —
STAFF USE ONLY
Permit Fee:
1-3
Perk Fee:
100
Total fees:
11.3
Fccs Paid:
133
Balance due:
Building Permit:
Septicc
Permit:
Ll
c�
4Issue
Date: D
fiuildin: & PI:ning De
..- _
•
11—/9- /2—
APPRO 'AL
r
DATE