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GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8"' Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www :irf field-counly.com
Parcel No: (this information Is available at the assessors office 970.945-9134)
•-•U•5-0a3 -01 _CIS' i
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
/7.36 C❑644-/r/s. �a ov 12. 4.52 5,-,•,$, ec, 131600
Lot Size: Lot No: Block No: Subd.l Exemption:
404(,/e--� (�1,V
Owner: (property owner)
Contractor:
Engineer:
VA I t- ai*blece4ah
PERMIT REQUEST FOR:
Mailing Address
t l 3!o Genu./ Z.A, I24
5.,coS/4o(
Mailing Address
Ph;
410.94/, /378
Ph:
Ph:
97049/.4033
Mailing Address
-Tara DK g407 Auo.C, co $(Lazo
(}cJ_ New Installation (S4 Alteration
WASTE TYPE: 04Dwelling ( )Transient Use
( )Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms /
( }Commercial or industrial
rC-
Alt Ph:
Alt Ph:
Alt Ph:
( ) Repair
( )Non- Domestic wastes
SOURCE &TYPE OF WATER SUPPLY: ( )WELL (1SPR1NG_
If supplied by COMMUNITY WATER, give name of supplier. M O Ail- t`� 6.
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: L M 1 L__f S
Was an effort made to connect to the Community System?
Garbage Grinder(X)Yes ( )No
UST�M ppR CREEK
IV A i S„ --JC LVC(-t ',A. frit)
( )CISTERN
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
GROUND CONDITIONS: ,,�
Depth to 15, Ground Water Table Percent Ground Slope /CPT,
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
(SOSeptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other- Describe
FINAL DISPOSAL BY:
(1QAbsorption trench, Bed or Pit ( )Underground Dispersal ( )Above Ground Dispersal
( )Wastewater pond ( )Other- Describe
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( )Composting Toilet
( )Evapotranspiration ( )Sand filter
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Will effluent be discharged directly into waters of the state?
( )YES (ANC)
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PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the Percolation Test)
Minutes /3 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: %I - 044al sim FbSf.- fito07 0.44C 0 'I(iZo
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by
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 perju I al's ded by law. Q('
OWNERS SIGNATURE DA
/3- i
Ci' c�l /61-3,
Permit Fee:
STAFF USE ONLY
Perk Fee:
`0
Septic Permit #:
\D,138"
i6ui ing& Nonni g Dept:
01(0i
Total fees:
Issue Date:
Building Permit #:
APPROVAL DATE