HomeMy WebLinkAboutApplicationczy-elc1 Couniy -I
_ -._ — 108 8th Street, Suite 401, Glenwood Springs, CO 81601
Ph:970-945-8212 Fx:970-384-3440 Inspection Line:888-868-5306
www.gar f ieid-countv.com
SEPTIC PERMIT APPLICATION
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Parcel No: (chis r forma on r' v labfe at the assessorl once 574-945.9134)
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Lot Size: Lot No: Block No: Subd./Exemption.
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Job Ad,drrs.s: (dap address has not n assigned, please provide CR, HWY or Street Name & City) or and legal description
`1`i CA Com. \2< ,
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Owner: (property ner)
C.-' 9i 1-- I�.).)t..�
Mailing Address
S- Co ... PC1.
Ph:
Alt Ph:
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Conti or:-�-`
kiPP
Mailing Address
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230-03
Alt Ph:
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Engin "�
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Mailing Address L
Po =,E t `/ r-Lent'tato,
Ph: i ��Q3 ,�
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PERMIT REQUEST FOR: () New Installation ( ) Alteration epair
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WASTE TYPE:Bing ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other -Describe
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BUILDING OR SERVICE TYPE:
Number of bedrooms D Garbage Grinder ( )Yes ( )No
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SOURCE & TYPE OF WATER SUPPLY: L ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier.
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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
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GROUND CONDITIONS:„.--, \ cJ
Depth to 1st Ground Water Tabic } Percent Ground Slope _ p
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YP INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
eptic Tank I )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
() ecycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other -Describe
FINA POSAL BY:
orption trench, Bed or Pit ( )Underground Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
( )Wastewater ( )Other- Describe
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pond
Will effluent be discharged directly into waters of the state? ( )YES ....-----
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PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineerdoes the Percdal' n Testi
Minutes per inch in hole No.1 Minutes per inch in hole No.3
Minutes J per inch in hole No.2 Mi utas per inch in hole No._
Name, address & telephone of RPE who made soil absorption test: <111 Ver—L—
Name, address & telephone of RPE responsible for design of the system: IA - +c2pry' 6 -LEN C) j -
Applicant acknowledges that the completeness of the application is conditional
the local health department to be made and furnished by the applicant
issuance of the permit is subject to such terms and conditions as deemed
reports submitted herewith and required to be submitted by the applicant
and are designed to be relied on by the local department of health in evaluating
understand that any falsification or misrepresen y result ip-tq
and legal action for perjury as provided _
upon such further mandatory and additional test and reports as may be required by
or by the local health department for purposed of the evaluation of the application; and the
necessary to insure compliance with rules and regulations made, information and
are or will be represented to be true and correct to the best of my knowledge and belief
the same for purposes of issuing the permit applied for herein. I further
ial of the application or revocation of any permit granted based upon said application
_
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OWNERS SIGNATURE
DATE
Permit Fee:
7C`
STAFF USE ONLY
Perk Fee:
Iota! fees:
Fees Paid: 5ro
Balance due:
Building Permit:
Septic Permit:
DATE
Issue D te•
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