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PHONE:
�✓� ek -
YES - NO -
ADDRESS: PHONE:
PERMIT APPLICATION IS FOR: '(>Q New.Installation -( ) Alteration ( ) Repair
LOCATION OF PROPOSED INDIVIDUAL SEWAGE DISPOSAL SYSTEM:
Street/Rural Address: jv 6 E-:3 1-4 P
Lot Size:
Legal Description:
i
BUILDING OR SERVICE TYPE (check applicable category):
(X) Residential - Single Family
( ) Residential - Duplex
( ) Residential Triplex
NUMRFR nF PFRSnmq-
WASTE TYPES (check applicable categories):
( ) Commercial or Institutional
( ) Non -Domestic Wastes
(�) Garbage Disposal
(X ) Automatic Washer
( ) Other
TYPE
OF
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM PROPOSED:
()
Septic Tank
(
)
Composting Toilet
(
)
Vault Privy
(
)
Greywater
(
)
Pit Privy
(
)
Aeration Plant
(
)
Other
' APPLICATION FOR INDIVIDUAL SEWAGE
DISPOSAL SYSTEM PERMIT
4
<<'
ENVIRONMENTAL HEALTH OFFICE
- EAGLE COUNTY
P.O. Box 850
Eagle, Colorado 81631
Q (�
No. to I
PERMIT APPLICATION FEE: $150.00
PERCOLATION TEST FEE: $50.00
NAME OF
OWNER::U
ADDRESS:
&&S-3
G v
4)PHONE:
NAME OF
APPLICANT (if
different from owner): -
ADDRESS:
--
PHONE:
DESIGN ENGINEER OF SYSTEM (if applicable):
ADDRESS: —
PERSON RESPONSIBLE FOR INSTALLATION OF -SYSTEM:
Licensed Installer (see attached list):
Residential - Quadplex
( ) Commercial (state usage)
NUMBER OF BEDROOMS:
(X ) Dwelling
( ) Transient Use
()C) Dishwasher
( ) Spa Tub
( ) Incineration Toilet
( ) .Chemical Toilet
( ) Recycling, Potable Use
( ) Recycling, Other Use
WILL`EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE: YES ( ) NO (x)
IS SYSTEM DESIGNED FOR LESS THAN 2,000 GALLONS PER DAY: YES ( X) NO ( )
WASTEWATER FLOW REDUCTION PLAN: YES ( ) NO ()
(I 6 Yeas, 6 ee attached wa3 ewa eA 4tow Leduc ti_on me thod,6 )
NOTE: The Env-itconmentat Health 04jicet may reduce the requited absotpti,on area upon
appnova2 o4 an adequate wastewatet 6Zow Leduc Lion plan.
SOURCE AND TYPE OF WATER SUPPLY: ( ) Well (X) Spring ( ) Creek/Stream
Give depth of all wells within 200 feet of system: None -
If supplied by yommunity water, give name of supplier:
SIGNATURE: DATE:'
- - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - -
INFORMATION BELOW TO BE FILLED OUT ByIM-
VIROMMENTAL HEALTH OFFICER:
GROUND CONDITIONS: PeAcent Ground Slope
Depth to Bedtco ck (pet 8' Pno 4it e Hot e )
Depth to GroundwateA Tabte
SOIL PERCOLATION TEST RESULTS: A nute/s pek inch tin Ho.2e l
M.inute6 pen .inch to Hone # 2
M.inutu peA .inch to Hote #3
FINALDI�OSAL By:
( �' Ab,5 oAption Trench, Bed on Pit ( 1 Evapot&am piAa ti.on
( ) Above Ground D.i spe&6a.2 ( ) Sand FiZtet
( ) Unde>ound DZ6peAzae ( ) Wastewateh Pond
( ) Other
Amount Paid: O Receipt Numbe& - U `-�,� Date: �Y-d 0� "?
NOTE: Site Plan must be attached to application.
(Env. Health Department - Rev. 4-07-83)
i.Y
• ` rf
0:1NEa : ZZ
LEGAL DESK` 1Pi 1UN:
o
RURAL ADDRESS:
TYPE OF DUELLING:
I OF BEnRnnmS : �
DATE OF PERCOLATION TEST: c�—�� �j�/` TYPE OF SOIL: Cl
TEST HOLES PRESOAKED? Yes No
TIME
WATER DEPTH
INCHES OF FALL
RATE
1
2
3
1
3
1
2
3
1
2
3
r� (
"l r5�
3z1
a2
(
1'a7
! ,off
�3s
4�-0
2
i
LI
i
-
I
II
IT
PERCOLATION RATE:
RECOP"MENDED MINIMUM SEPTIC TANK SIZE:
RECOMMENDED MINIMUM LEACH FIELD SIZE: �dr�
RECOMMENDED MINIMUM SQUARE FOOTAGE PER kDROOM:
Site has been reviewed and tested for percol o rate.
Date Environmental Heat fi icer
COMMENTS:
CIA -
JOB NAME,
AGt�fy/ �rc� JOB NO.
JOB LOCATION
BILL TO
DATE STARTED
PERMIT NO. 662
OWNER: Nottingham Ranch Company
6653 Derby Mesa Loop - Burns, CO
LOCATION: 6653 Derby Mesa Loop
DATE COMPLETED
INSTALLER: Owner
SIZE OF TANK: 1,000 gallons - Degrees: 90 Feet: 40-45
DWELLING: 3 bedroom - x 200 sq.ft.
PERC RATE: one inch/20 minutes - 600 sq.ft. absorption area.
DATE BILLED
JOB COST SUMMARY
TOTAL SELLING PRICE
TOTAL MATERIAL
TOTAL LABOR
INSURANCE
SALES TAX
MISC. COSTS
TOTAL JOB COST
GROSS PROFIT
LESS OVERHEAD COSTS
% OF SELLING PRICE
NET PROFIT
Finalized: 6/22/84 By: Erik Edeen
Printed in U.S.A.
LDER
d�
5 ��FU�-