HomeMy WebLinkAboutApplicationGARFIELD COUNTY SEPTIC PERMIT APPLICATTON
108 8ú Skeet, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 I Fax:970-384-3470 / Inspection Line: 970-384-5003
I Parcel No: (his information is available at he assessors office 970.945-9134)
2179-O9L-AO-042 Perrnit/l
2 Job Address: (if an address has not been assigned, please provide Cr, Hwy or Sbeet Name & City) or and legal descriptíon
3295 River Frontase Road. Silt. CO 8L652
J Lot Size:
27.47 Ac.
Subd./ Exemption:
Sievers Amended
Lot No:Block No:
3
AIt Ph:
970-404-2424
4 Owner: (property owner)
Simon Casas
Mailing Address
1lB Euclíd Avenue
Carbondale. CO 81623
Ph:
97 0-963-2777
5 Coniractor:Símon Casas CarbondaleMailino Address
118" Euclid Ave
Ph:
97 0-963-2777
AIt Ph:
970-404-2424
Mailing Address
P-O. Box 1458 Gws. CO 81602
Ph:
97 0-qL\-? \\O
AIt Ph:qin-9/+8-i1 Lq
6 Engineer:
Gamba & Associates, Inc.
7 PERMIT REQUEST FOR:( ) New lnstallation ( ) Alteration ([)Repair
8 ( )Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
k)Other-Describe R V Park
WASTE TYPE:
I BUILDING OR SERVICE TYPE;
Number of bedrooms Garbage Grinder ( )Yes ( )No
l0 (iwELL ()SPRTNG ()STREAMORCREEK ()CISTERN
lf supplied by COMMUNITY WATER, give name of
SOURCE & TYPE OF WATER SUPPLY:
l1 DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 400 '
Was an effort made to connect to the Community System?fìna + D*nl'r' l-.-í +i-'^
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
t2
Percent Ground Slope--- 3Z-GROUND CONDITIONS:
4',Depth to lstGround Water
13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS)il: Existíng
jç{Septic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )lncineration Toilet ( )Chemical Toilet
{2.)Other-Describe Advan TR)L FíLterl
l4 FINAL DISPOSAL BY:
þ{Absorption trench, Bed or Pit
( )Wastewater pond
(
(
( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
l5 Will effluent be discharged directly into unters of the state? ( )YES (ENO
16 PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if fre Engineer does he Peicolation Test)
per inch in hole No.1 Minutes_ per inch in hole No,3
perinchinholeNo'2Minutes-perinchinholeNo,-
Name. address & teleohone of RPE who made soil absorption test:
Name, address & telephone of RPE responsible for design of the system:
r rfaa
r rlacN/A (Repair)Min
Min
conditional upon such further mandatory and additional test and reports as may be required by
the local health department to be made and furnished by the applicant or by the local health departmeni for purposed of the evaluation of the application; and the
issuance of the permii 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
result in the denial of the application or revocation of any permit granted based upon said application
DA
Applicant acknowledges that the completeness of the application
understand that any falsification or misrepresentation may
OWNERS SIGNATURE
and legal action for perjury as provided by law
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Total fees:Building Permit #:
NI AryPermit Fee:c:O Perk Fee:
Issue Date:rsÙrrçr'zrf,c;Iil\51
cbSeptic Permit #:
/r-f 4540
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