HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8th Street, Suite 401. Glenwood Springs, Co 8160I
Phone: 970-945-8212 Fax: 970-384-3470 ; Inspection Line: 970-384-5003
w-ww. arfeld-co orn
l
Parcel No: (this information is available at the assessors oitice 970-945.9134)
AWI—Ql1—1—CO" u)•
2
Job Address: (if an address has not been assigned, please provide Cr, Hwy or tree!
ame & City) or and legal description
3
L t .ze: Lot No: Block No: Subd! Exemption:
4
Owner: (property owner)
010W1) 'C
Mailing Address
)151.1- Q r rem elite
Ph:
- 15-4 z4Liq
Alt Ph:
Alt Ph;
5
Contractor:
Mailing Address
Ph:
6
Engineer
Mailing Address
Ph:
Wt Pn;
7
PERMIT REQUEST FOR: K. New Instailation ( 1 Alteration ( ) Repair
---
8
WASTE TYPE: eking ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other — Describe
9
BUILDING OR SERVICE TYPE:
Number of-bedr oms Garbage Grinder ( )Yes ')No
10
SOURCE & TYPE OF WATER SUPPLY: WELL ( )SPRING ( )STREAM OR CREEK CISTERN
If supplied by COMMUNITY WATER, give name of supplier.
1 I
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1t Ground Water Table Percent Ground Slope
13
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
Other- Describe
14
F INAL DISPOSAL BY:
sorption 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
16
PERCOLATION TEST RESULT: (to be completed by Registered ProtessionaI Engineer, it the Engineer does the Percolation 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:
Applicant acknowledges
the local health
issuance of the
reports submitted
and are designed
understand that
nd legal actio
that the completeness of the
department to be made and furnished
permit is subject to such terms and
herewith and required to be submitted
to be relied on by the local department
any falsification or misrepresentaf'
i or •�ury as p ed by law.
application is conditional upon such further mandatory and additional test
by the applicant or by the local health department for purposed of the evaluation
conditions as deemed necessary to insure compliance with rules and regulations
by the applicant are or will be represented to be true and correct to the
of health in evaluating the same for purposes of issuing the permit applied
y result in the denial of the application or revocation of any permit granted
*y
af--0
and reports as may be required by
of the application; and the
made, information and
bast of my knowledge and belief
for herein. I further
based upon said application
17
WNERS SIG
r T 'a DATE
STAFF USE ONLY
Permit Fee:
Perk Fee:
Total fees:
Building Permit #:
Septic Permit #:
Issue Date:
Building & Planning Dept:
APPROVAL DATE