HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8`h Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-34701 Inspection Line: 888-868-5306
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Parcel No: (this information is available at the assessorsoffice 970-9459134) CJ p L
o� 1 ! 3 3 a ! ®0 0'31-
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Job Address, (if an address has not been assigned, ase provide Cr, Mvy or Street Name 8 City) or and" description
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GCS'
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Lal Size: Lot No: Block No: Subd! Exemption:
35,vc; (o p
Septic Permit #:
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Owner (property owner)
Mailing Address
Ph: q a r
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Alt Ph: Q q 59
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Contractor,
Mailing Address
Ph:
Alt Ph:
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Engineer.
Mailing Address
Ph:
Alt Ph:
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PERMIT REQUEST FOR: &A New Installation () Alteration (J Repair
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WASTE TYPE: Q4Pwetling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other—Describe
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BUILDING OR SERVICE TYPE: U 41 rn ' !c t ;
Numbel,6f bedrooms Garbage Grinder es XNo
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SOURCE & TYPE OF WATER SUPPLY: PqWELL { )SPRING ( )STREAM OR CREEK ( )CISTERN
N supplied by COMMUNITY WATER, give name of supplier.
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DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: h/ 2.,^ 10 1- h
Was an effort made to connect to the Community System? A/0
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
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GROUND CONDITIONS:
Depth to 1 It Ground Water Table Percent Ground Slope
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TYPE 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
Cher- Describe
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FINAL DISPOSAL BY:
,)Absorption trench, Bed or Pit ( )Underground Dispersal ( )Above Ground Dispersal { )Evapotranspiration ( )Sand filter
( )Wastewater pond ( )Other -Describe
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Will effluent be discharged directly into waters of the state? ( )YES KRO
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PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, If the Engineer does the Perculation Test)
Minutes per inch in hole No.1 Minutes per inch in hole No.3
Minutes per inch in hale 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:
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by
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the local health department to be made and fumished 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 pro ' ed by taw. ,
OWNERS SIGNATURE4 4,4DATE /0--
(, 'S - S i `* STAFF USE ONLY
Permit Fee:
Perk Fee:
Total fees:
Permit #:
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GCS'
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�Building
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Septic Permit #:
Issue Date:
G
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Building & Planning Dept:
APPROVAL
DATE