HomeMy WebLinkAboutApplicationTCZ 7--f2 4 ICY G'CP ZL 32 Zy
.11040''' 108 8th Street Suite 401, GlcrnroodSprings, CO 81601
Ph:970-945-8212 Fz:970-384-3440 Inspection Line:888-868-5306
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SEPTIC PERMIT APPLICATION
ft ECE WEn
GARFIELD COUNTY
BUILDING & PLANNING
STAFF USE ONLY
Permit Fee:
73
Perk Fee:
122-
1r7d
Parcel No: (thisfn1amaam is avartanla at the assessors office 970445.9134)
a Lot Size: Lot No: Block No. SubdJExempion
2
Job dress: ( Han address has nal been assigned, please provide CR, HWYor Sheet Name dCdfy)aand legal desapion
wee " O 7 Co; V) ° 2 441 /Il f'4, jF f
d
Issue Date:
il/d 6)
' Owner. (propel, mewl
,„1-`.i 4
Marling Address 5,.,!> (,2,--
/in ,24-,.7,4- /4 f‘Qty
Ph:
8'o/ --i of - 4r 6.2 #i-
Nt Ph:
770.-2/3_ 92 07
5
,
Contractor.
Ma°iing dress
Ph:
Alt Ph:
G
Engineer
Marling Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: New Installation () Alteration ( ) Repair
8
WASTE TYPE: bdDweling ()Transient Use (}Cammeraai or industrial( )Non- Domestic wastes
( )Other – Describe
9
BUILDING OR SERVICE TYPES, ..; /c F• . , ° ! +
Number of bedrooms Garbage Grinder ( )Yes ttig)No
10
SOURCE & TYPE OF WATER SUPPLY: rOWELL ( }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 tin Communtty SystenrT
t .,,fro
.
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1d Ground Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISOs) PROPOSED:
(Septic Tank ( )Aeration Plant ( }Vault ( Wad Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( flt Privy ( )Incineration Taiet ( }Chemical Todet
( )Other- Describe
141
FINAL DISPOSAL BY:
f}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 MHO
I6
PERCOLATION TEST RESULT: (to be arepletedty Registered Rofesoonmi Engineer, if the Engineer does Ine PercdabonTest) -
Minutes per inch in hole No.1 Minutes per inch in hale
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 end reports as may be required by
the local health department to be made and furnished by the appicant 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 compiance 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 carred 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 tithe appicafon or revocation of any permit granted based upon said application
and legal action fo 11:as pipided b
f /,
OWNERS SIGNATURE DATE
STAFF USE ONLY
Permit Fee:
73
Perk Fee:
122-
1r7d
Total fees: D O
i 7 3
Fees Paid:
f-3.
Balance due:
Building Permit:
311
Septic Permit:
3g
Issue Date:
il/d 6)
g & PI. 'ng Dept
i,
,di–o-e...-.. 7A/Z—
APPROVAL. I/ E
