HomeMy WebLinkAboutApplication1088'a Sheri Suite 401, Gkmrood Springs. CO 81601
Ph: 970-915-8212 Fs:970-384-340 Inspection Line:888-868-5306
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SEPTIC PERMIT APPLICATION
JUL 3 0 2012
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-.lob'Addre cWaealdesseasaal•-. assigned plessep abCF4MYrffsrseIName i 1:11") mad bpirbsalplks
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79-54-78
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PEIiIN'�T1 () Newer ( ) Atleratio5 .1 ie
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WASTE•
41 .: , ()Transient Use ()C.an orirdl�ial ( worn- i i ate.; waste
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9W.DING OR SERVICE TYPE:
Number ofbedrooms , Garbage (1No
SOURCE &TYPE OF WATER SUPPLY:( y
If supplied by TY WATER, give maned supplier, t Y-9, w moi- OR CREEK (1CiSTERN
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DtSTANCE'fOIEARE87 I ' $EWEMint - r_..
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-YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
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GROI !I COND1TIOl �f
Depth b1aGround Water Table Percent Ground Slope / '
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TY1?E OF (NDWIDUAL SEWAGE DISPOSAL SYSTEM (MS) PROPOSE):
Ft** Tar& ()A ati n Plaid ( )Vault ( }Vault Privy (}Composting Toilet
)Recycling, Pdable Use ()Recydrtg, other use ()Pt Privy ()lrrlrreration Toilet ( )Chemical Timet
t }Ober- Describe
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^ • DISPOSALL BY: — - , �
ti. i. ,. ,'i i bench, Bed ry / ( }Underground Dispersal ( )Above Ground Chpwow ( }Evapotranspiration ( pand filter
)Wastewater pond V ()0thw . Describe
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Wd effluent be discharged directly Into waters of the stats? ( )YES
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PERCOLATION TEST RESULT: (b be mmpieid I* Raplslend Ps at Enpieer. Il an Ensiaerdoes be Pen:onion Ted)
Minden per inch in hole No.1 Minutes per inch In hole No.3 S
lades per Inch in hole Not Minutes per inch In hate No_
Name, address & telephoned RPE who made soil absorption test
Name, address & telephone of RPE responsibb for design of the system
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Applicant adwowledges that the completwiess of the application b conditional upon sudh irstfmr mandatory axl additional test and sports as may be required by
the sod health department to be made and fumbhed by the applicant or by the local health departure d for purposed d the evaluation of the appiicabart and the '
lssri ince of the perrril is subject to such terms and condign as deemed necessary to inure C0111101We with odes and regi hs made. Information ad
reports submitted herewith and wired to be submitted by the applicard M area be represented to be true and correct to the best of my knowledge and belief
and are designed to be relied an by the local deperbeent of health in warding 'the same for purposes of issuing the permit applied for herein. I further
understand that any mon or misrepresentation may remain the denial dile application or revocation claw permit granted based upon said appTicatian
and Inth Fro�rldr .bby1Ine _
moo* RE DATE
STAFF USE ONL
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APPROVAL
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