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Home My WebLink About113 Kirk Ln - 210904203001• APPLICATION FOR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT ENVIRONMENTAL HEALTH OFFICE - EAGLE COUNTY Number: P 0 BOX 179 ' EAGLE, COLORADO 81631 U'A 949-5257 Vail 328-7311 Eagle 927-3823 Basalt P uPFRCO.LATIO�� NEST FEE'12.5 00 ER"1IT APPLICATIO FREE$150 00As. NAME OF OWNER: air — MAILING ADDRESS: j6o,Y 6,19 o6ke- , L9o% PHONE: 6-3 9. NAME OF APPLICANT (If different from owner): S41n6 ADDRESS: PHONE: DESIGN ENGINEER OF SYSTEM (If applicable): Lj- ADDRESS: -,44 , PHONE: PERSON RESPONSIBLE FOR INSTALLATION OF SYSTEM: S Am G J LICENSED INSTALLER:. YES ( ) NO ADDRESS: l qOO B C f- /V &l,,, 615. PHONE: ,99 9- �,6 4/I PERMIT APPLICATION IS FOR: ( V� NEW INSTALLATION ( ) ALTERATION ( ) REPAIR LOCATION OF PROPOSED INDIVIDUAL SEWAGE DISPOSAL SYSTEM: _ Nnys i ca l Naaress : I " V4R,3� y�� Parcel Number: Z Lot Size: Legal Description: i Z BUILDING 0 SERVICE TYPE (Check applicable category): Residential - Single Family ( ) Residential - Fourplex ( ) Residential - Duplex ( ) Commercial (Type) ( ) Residential - Triplex NUMBER OF PERSONS: A_ NUMBER OF BEDROOMS: WASTE TYPES Check applicable cate4ories : Commercial or Institutional ( ) Dwelling Non -Domestic Wastes ( Transient Use (�) Garbage Disposal ( ) Dishwasher ( ✓) Automatic Washer ( ) Spa Tub ( ) Other (Specify): TYPE OF INDIVIDUAL 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 NO IS SYSTEM DESIGNED FOR LESS THAN 2,000 GALLONS PER DAY: YES ( ) 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: AJ,4. If supped by mmunity water, give name of supplier: oLo q �.WE . SIGNATURE��!/�.c. DATE: /-©? 6- 9o, INFORMATION BELOW TO BE FILLED OUT BY ENVIRONMENTAL HEALTH OFFICER: GROUND CONDITIONS: Percent ground slope O — /O SOIL Depth to Bedrock (Per 8' profile hole)7 R Depth to Groundwater table ' PERCOLATION TEST RESULTS: cb Minutes per inch in Hole #1 7„5, Minutes per inch in Hole #2 /3' Minutes per inch in Hole #3 FINAk DISPOSAL BY: Absorption Trench, Bed or Pit ( ) Evapotranspiration Above Ground Dispersal ( ) Sand Filter ( ) Under Ground Dispersal ( ) Wastewater Pond ( ) Other AMOUNT PAID: r% r o RECEIPT NUMBER DATE: NOTE: SITE PLAN MUST BE ATTACHED TO APPLICATION. MAKE ALL REMITTANCE PAYABLE TO: "EAGLE COUNTY TREASURER". (Environmental Health Dept. - Rev. 4/88) R• fe 5�v Date Rut ROUTE FORM EAGLE COUNTY ENVIRONMENTAL HEALTH OFFICE Ex', ( Appl icattioon `No. (Location) -7 v ` Please review the attached Individual Sewage Disposal System Permit Application and return it with this completed form the the Environmental Health Office. PLANNING: Complies with - YES NO REVIEUED BY DATE Subdivision Regulations: Zoning Regulations: 2 ,� Recommend Approval: COMMENTS: BUILDING: Complies with - YES NO REVIEWED BY Building Permit Applied For: Buildina Permit Issued: Recommend Approval: COMMENTS: ENGINEER: Complies with - Roads: Grading: Drainage: Recommend Approval: COMMENTS: DATE 'ES NO REVIEWED BY DATE ENVIRONMENTAL HEALTH: Complies with - YES NO REVIEWED B Floodplain Permit Necessary: e I.S.D.S. Regs. Compliance: Recommend Approval: i COMMENTS: DATE LLI Q -0 Z a C .� # �K, 3 L 20c) •`"M.� • M ' t'•' 959 Smith Lot 28 KirkolaNE E � �� .�cn:j JOB NAME 113 Kirklane 2109-042-03-003 JOB NO. JOB FOU 5-0 `�. J Q�z Q Z ;�. w � ' ^ = Q J L u J W W W Q c J F- H W ❑ � 1\ ° } W W ( Lu w Q O F Z Z (� WLu Q t m O ° m � W o �Z QU, �. W° Q \, V w W J c ❑ wv_' �V Q W Z O 2 CL w CD r W LLI J O O ~ w �[ or 0 ❑ ed in U.S.A.