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APPLI_CATION FOR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT
ENVIRONMENTAL HEALTH OFFICE - EAGLE COUNTY Number:
P. 0. BOX 179
EAGLE, COLORADO 81631
949-5257 Vail. 328-7311 Eagle 927-3823 Basalt
PERMIT APPLICATION) FEE �!5
NAME OF OWNER:
MAILING ADDRESS:
NA14E OF APPLICANT (If different from owner):
ADDRESS: _ v ►� -
DESIGN ENGINEER OF SYSTEM (If applicable):
ADDRESS: O21Co ,�a4e7,# gr I/M
PERSON RESPONSIBLE FOR INSTALLATION OF SYSTEM:
LICENSEQ INSTALLER: ( X YES ( ) NO
ADDRESS: a 8)99
PERCOLATION TEST FEE 51X001%
ONE
3:
PHONE:
g/G,a PHONE:�s''%
PERMIT APPLICATION IS FOR: ( ) NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
LOCATION OF PROPOSED INDIVIDUAL SEWAGE DISPOSAL SYSTEM:
Physical Address: as Q1 I n-IT. UI e"4D f)-( 0-e-
Parcel Number: 1 1+ Lot Size: a� �r Z Ctre-S
Legal Description: Lot 14--, _ AK r +dg� I j' M-C, Uk t�l-� l�a+►�I7
BUILDING OR VWCE TYPE (Check applicable category):
Residential - Single Family ( ) Residential - Fourplex
( ) Residential - Duplex ( ) Commercial (Type)
( ) Residential - Triplex
NUMBER OF PERSONS: NUMBER OF BEDR00MS:
WASTE TYPES Check applicable categories):
Commercial or Institutional (}-Dwelling
Non -Domestic Wastes ( ) Transient Use
(� arbage Disposal ( --r Dishwasher
( Automatic Washer ( .A' Spa Tub
( ) Other (Specify):
TYPE OF INDI IDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
Septic Tank Composting Toilet ( ) Incineration Toilet
( ) Vault Privy ( ) Greywater ( ) Chemical Toilet
( ) Pit Privy ( ) Aeration Plant ( ) Recycling, Portable Use
Other ( ) Recycling, Other Use
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE: ( ) YES (� 0
IS SYSTEM DESIGNED FOR LESS THAN 2,000 GALLONS PER DAY: ( ES ( ) NO
WATER CONSERVATION PLAN: (�` YES ( ) NO
NOTE: The Environmental Health Office may reduce the required absorption area upon
approval of an adequate water conservation plan.
SOURCE AND TYPE OF WATER SUPPLY: ( ) Well ( ) Spring ( ) Creek/Stream
Give depth of all wells within 200 feet of system:
If supplied by community Ovate give name of supplier: —� GLn L� I�etic����r �f �
SIGNATURE: DATE:
INFORMATION BELOW TO BE FILLED OUT BY ENVIRONMENTAL HEALTH OFFICER:
GROUND CONDITIONS: Percent ground slope
Depth to Bedrock (Per 8' profile hole) >
Depth to Groundwater ble Z �.
SOIL PERCOLATION TEST RESULTS: t Minutes per inch in hole #1
Minutes per inch in Hole #2
Minutes per inch in Hole #3
FINAL DISPOSAL BY:
Absorption Trench, Bed or Pit ( ) Evapotranspiration
Above Ground Dispersal ( ) Sand Filter
( ) Under Ground Dispersal ( ) Wastewater Pond
( ) Other
AMOUNT PAID:
RECEIPT NUMBER 3 g' DATE: f �
rfirry �.i'ansrn I i Pl1CLfTCO•
K
NOTE: SITE PLAN MUST BE ATTACHED TO APPLICATION.
MAKE ALL REMITTANCE PAYABLE TO: "EAGLE COUNTY TREASURER".
(Environmental Health Dept. - Rev. 4/88)
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