HomeMy WebLinkAboutApplication- PermitAssessor's Parcel No.
CHARGES
Percolation Test $100.00
(includes final inspection)
Permit Processing Fee $50.00
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vloney Order
Owner's Name
knit N
3466
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Address at System Location53' (7 (' R t 54 A(12-4•44-0,
(1„t, ,u y)
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Amount Paid� '?(i�1�i� • , •• - _
Date Paid
Cashier (1)
ALL CHECKS ARE TO BE MADE PAYABLE TO GARFIELD COUNTY TREASURER
While - APPLICANT Yellow - DEPARTMENT
5-e-noco,
OWNER
ADDRESS
INDIVIDUAL SEWAGE DISPOSAL S
LLC
ON
?sc. $w6%, --7/
CONTRACTOR
1E' 185- CA?Asa a'Av-e c0 /4311023
1'*t% G F.0 1— CvNT P -n cro�S
PHONE %i.
ADDRESS fySH ea iAgCSa,. ,At. a23 PHONE `% 1,s-- E4.-‘ 9
PERMIT REQUEST FOR a NEW INSTALLATION qq ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
j.00ATION OF PROPOSED FACILITY:
Near what City of Town 440.,vNooa `�,z Nc (-o Size of Lot 4. sae' Ac,zc.
Legal Description or Address 531"7 Cov„ri roero 1s4 , yioiooti SKS (y 75 - K89 W - Sr,_ 1 )
WASTES TYPE: (>4 DWELLING ( ) TRANSIENT USE
p'3 COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: IQE4'1:1E.x,AI- / OFFza 1 Lk; tiva-
Number of Bedrooms SE CA 1-4- s Number of Persons ses cies ,
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
A site elan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigatlon Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER - DESCRIBE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
PERCOLATION TEST RESULTS. (To be completed by Registered Professional Engineer, if 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 and telephone of RPE who made soil absorption tests:
-7; e_ �& Tex 43.1 GAP. >>At a; to $1t,z-S ' L3- ?EA,
Name, address and telephone of RPE responsible for design of the system:
SRA,* AS Asa.iz —
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and
additional tests and reports as may be required by the local health department to be made and furnished 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 in legal action for perjury as provided by law.
Signed
& A Date
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3