HomeMy WebLinkAbout10651 Hwy 6 - 211105108002Green ;Copy "'A i cant/Own"er
f.
APPT ICATION FOR INDIVID
UAL SEWAGE DISPOSAL SYSTEM PERMIT
ENVIRONMENTAL HEALTH OFFICE - EAGLE COUNTY
P.O. Box 850
Eagle, Colorado 81631 No. 10EY-1
PERMIT APPLICATION FEE: $150.00 PERCOLATION TEST FEE: $50.00
NAME OF OWNER: X11 Jy V AJ0 K FL Af
ADDRESS: _ � 2 3 I , ec- ll PHONE: Z y _ cJ --
NAME OF APPLICANT (if different from owner):
ADDRESS:
DESIGN ENGINEER OF SYSTEM (if applicable):
ADDRESS:
PERSON RESPONSIBLE FOR INSTALLATION OF SYSTEM:
PHONE:
PHONE:
Licensed Installer (see
ADDRESS : �, C o z' y
attached list): YES
h1 ,-_'5 it,K a %h 0
NO
PHONE:
PERMIT APPLICATION IS FOR:
() New Installation ( )
Alteration
( ) Repair
LOCATION OF PROPOSED INDIVIDUAL SEWAGE DISPOSAL SYSTEM:
Street/Rural Address:
' C 'L / Z--)} C'
i"s 6L.%94
Lot Size:
jm L i2 5
Legal Description:
`
BUILDING OR SERVICE TYPE (check an licable cat
P
Residential - Single Family
Residential - Duplex
Residential - Triplex
( ) Residential - Quadplex
(� Commercial (state usage)��'�i�
Sfvi2L'
NUMBER OF PERSONS: NUMBER OF BEDROOMS:
WASTE TYPES (check applicable categories):
( ) Commercial or Institutional O Dwelling
( ) Non -Domestic Wastes ( ) Transient Use
( ) Garbage Disposal () Dishwasher
l` 0 Automatic Washer ( ) Spa Tub
( ) Other
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(x) Septic Tank ( ) Composting Toilet ( ) Incineration Toilet
( ) Vault Privy ( ) Greywater ( ) Chemical Toilet
( ) Pit Privy ( ) Aeration Plant ( ) Recycling, Potable Use
( ) Other ( ) Recycling, Other Use
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE: YES ( ) NO (�)
IS SYSTEM DESIGNED FOR LESS THAN 2,000 GALLONS PER DAY: YES (y�) NO ( )
WASTEWATER FLOW REDUCTION PLAN: YES ( ) NO ( )
(16 yeas, see attached waatewateA stow reduction methods)
NOTE: The Envitonmentat Heatth Ojj.ieen may tceduce the nequiked abzonpti.on area upon
appnova?- o4 an adequate wastewaeA 4tow neducti.on plan.
SOURCE AND TYPE OF WATER SUPPLY: ( ) Well ( ) Spring ( ) Creek/Stream
Give depth of all wells within 200 feet of system:
If supplie b__A��
y community water, give name of supplier: �'�/�Sc�.m /`�• iL y✓ (�
SIGNATURE: DATE• 1.� ��` �/
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INFORMATION BELOW TO BE FILLED OUT By ENVIRONMENTAL HEALTH OFFICER:
GROUND CONDITIONS: Peheent Ground Scope 0
Depth to Bedno ck (pets 8' Pno 4 i ?_e Hote)
Depth to GnoundwateA Tabte ,gyp
SOIL PERCOLATION TEST RESULTS:. -;-,. 0 _i1 tinute/s peA inch in Hole# 1
2-0 Minutes pets -inch to Hote # 2
2 *-2 Minutes pen .inch to Hote # 3
FINAL DI AL By:
( Ab/sonpti.on Ttceneh, Bed on Pit
( ) Above Ground Di,6peuat
( ) UndeAgnound Dtis peAz at
( ) Other
Amount Paid: A0 C0.0 D -
( ) EvapotAan6 p itr atio n
( ) Sand F,i Q tvL
( ) Wat tewaeA Pond
Receipt Numbek 0114 a,
NOTE: Site Plan must be attached to application. — Q,. 10e,C,L
(Env. Health Department - Rev. 4-07-83)
PF ,T 1 C"
tOS�
0:•tiaEa:
r f��
LEGAL
DESCRIPT1O`+:
RURAL
ADDRESS:
1Lp (10 a.-X, LA'j- &&1l9
— SLA-M
TYPE OF DUELLI'!G:
S.kt`Z Ot M
— - C S
\�9
c 1 OF BEDPnnms:
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ,
DATE OF PERCOLATION TEST:
TEST HOLES PRESOAKED? Yes
No
TYPE OF SOIL:
TIME
WATER DEPTH
INCHES OF FALL
RATE
1
2
3
1
2
3
1
2
3
1
2
3
7:;?U
2&
u
PERCOLATION RATE: 2 C! ���--
RECOMMENDED MINIMUM SEPTIC TANK SIZE: 12-:�
RECOMMENDED MINIMUM LEACH FIELD SIZE:��
RECOMMENDED MINIMUM SQUARE FOOTAGE PER BEDROOM:
Site has been revievied and tested fo ercolation rate.
Date Environmental Health icer
COMMENTS:
rLTQb-� 4C �e�! a.� 1 4' �� -
i
oz, 7'ln e1Z 5617�
Tlf
J Y
I
[ �
J
J
`"-i
m �
� Z
'.9 Q
�' �
LL�
'� �
� Q
�. 1
JOB NAME, 4LO ,Jp@, Na
JOB L®CATION
BILL TO
DATE STARTED DATE COMPLETED DATE BILLED
P€RMIT NO. 658
OWNER: Fred Hartlee j
16623 Hi hwa - e-
g y 6 Gypsum, CO 81637 (Box 355)
LOCATION: 16623 Highwat 6 - Gypsum (2 acres) <
INSTALLER: Randy Hill
SIZE OF TANK: 1,250 gallons Degrees: 0 Feet: 13'6"
DWELLING: Hardware Store (Commercial) aue,
PERC RATE: one inch/20 minutes
600 sq.ft. - leach field
FINALIZED: 6/18/84 BY: Sidney Fox
T,
LDER
I.