HomeMy WebLinkAboutNext to KOA Basalt - 000000000000ENVIRONMENTAL HEALTFi�`.e7
P.O. BOX 811
PERMIT NO. EAGLE, COLORADO 81631 PERMIT FEE $25.00
APPLICATION FOR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT
Name of Owner: D� 1%l D A IVi )3 s �/a /G Phone: 9� -7 - 3 9
Address of Owner: q 7 3 7319 S /9 L T_ LU
Is facility within boundaries of a city/town or sanitation district?
Distance to nearest sewer system: 1<0 ,6
Location of Proposed System:
Legal Discription:
Type of Structure: Single Family Dwelling ( ) Other: 12' No. Bedrooms
Water Supply: Private Well ( ) Location: c Distance From leach field:
Size of Lot:
Public Water Supply:
An appropriate plat plan must accompany site inspection for this application showing required information. (See
attached sheet.) The individual sewage disposal system will be constructed and installed in accordance with the
regulations governing individual sewage systems within Eagle County, and shall comply with House Bill 1553 CRS
66-14, 1973. Payment shall be made to the Eagle County Treasurer. Permit, upon approval of this application, may be
obtained at the Eagle County sanitarian's office.
Appointment for final inspection must be made prior to construction by contacting the inspecting sanitarian. [Phone
328-7718 between 8:30 and 9:00 AM.] Refer to permit number. No approval will be given on any system without final
inspection.
Name, address, and telephone of person responsible for design of system:
The undersigned acknowledges that the above information is true and that false information will invalidate the
application or subsequent permit.
SIGNATURE OF APPLICANT: Date:
G!J 42 T his application becomes invalid 6 months from above date.)
HEALTH DEPARTMENT USE ONLY
Percolation Information:
Tank Capacity: ��' gal. (minimum)
Absorption Area: Sq. ft. (minimum)
REMARKS:
e-W
APPLICATION IS: APPROVED ( ) DENIED ( )
Permit No._
Fee Receipt:
File:
The above individual sewage disposal system was installed by
AND HAS BEEN INSPECTED AND APPROVED BY A REPRESENTATIVE OF THE EAGLE COUNTY HEALTH DEPT.
Date: Sanitarian:
-L;
CO
Ih:." ID,
Street Address or _ _'gal. Description: v ' ��X� / AK —
DO
is
D,at e Of Test: �cl -?/ -,)epti" O.LPOZ e: 3' .. crletei ��" Tyi,e of soil:
—��-4��'}�J—
G-r�Ri G M
iGeat7.o1. of Test _iol e:
Test hole was ` re.'�_.oc:;{ee
(Tili?e) 23t21 . (Time) Pee:
-.s T-o
OF
Lp
z0
5(0
No
Ito
C fly
ISI
Ito
it 0
Percolation Rate: '30 1?i
Site has been revierred and tested for Percolatlfon rate.
Ue reco=..cnd: 1—JO AL (&-,�D?SA-D. ? OAT Date: G `'Z6 ._'7
i.r II i'LJt r,lan 'SiZJTvl ly i?GLi2lda�y lines, location of proposed bu 1 din` Or Ci1lC12i1�'S
and dcs2-n Of se . tiC "S im t bile �t � I h "•,ri � � 2 S� tE'G _c.lis uLJ i_ttCG TTit t_� I.- t'.Oi? .L0 � er llt tO �OnStrLCt.
The back :, of this fort may be used to show plot 'filar. -and desr-ll Of system.
By:
J !11 tam rc:I?
P. 0. Bo 011
teleprione (3'�'03 32° 771E
� �' Ea -le, Colorado 8163
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