HomeMy WebLinkAboutApplication.pdfcG Garfield County Community Development Department 1088'" Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.g arfield~county .com TYPE OF CONSTRUCTION JllI New Installation
10 Alteration WASTE TYPE INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PERMIT APPLICATION 1 o Repair 0 Dwelling 1 0 Transient Use 10 Comm/lndust rial 10 Non-Domestic o Other Describe INVOLVED
PARTIES Property Owner: /jeeVrork i(es-(J lI{'('Ps J... L( ' . Phone: (1 ')0 ) 62 c ) -22"2-LJ Mailing Address: P.O . ~" I' U b~ • <:;' . (f (\;, /0. ' f£,lbS2, Contractor: l -fo NT"
. .. r ~< >"v " "'$ ];N C Phone: (e , Q0 ) b 2-'> '-"2 :2 ~H Mailing Address: P. 0 . i3" l( ) 16 ~ , 5',' U-, Cal., . Z I{,'$2-Engineer: :c:,(Y()7 ,J e·rj: · ~."l1Q,tJ S o ,J Phone:
(~) 7 'i J -) 00 '-I Mailing Address: ll'6 l\.i''''' of 6 Li >;1; S,,-,' f e 200 b-J.. ,ViV"~ S/}r ...~ ·c Co),..l ' 8 /60L PROJECT NAME AND LOCATION Job Address: N o+ '1e.+ a.... ~
S ,Ie:-tVe c.~ Assessor's Parcel Number:.:? I?? -I 8'1-"YJ -'/20Sub. lot --Block --Building or Service Type: "Bedrooms: Garbage Grinder_ Distance to Nearest Community Sewer System: "3
,.,.,;Ie ~ Was an ~ffort made to connect to the Community Sewer System: N o Type of ISDS o septic Tank I 0 Aeration Plant I [] Vault I [] Vault Privy I 0 Compostlng Toilet o Recydlng,
Potable Use c] Recycllns I 0 Pit Privy I D Indneration Toilet o ChemlcalToliet [] Other Ground Conditions Depth to 1" Ground water table I Percent Ground Slope Final Disposal by [] Absorption
trench, Bed or Pit I [J Underground Dispersal I [] Above Ground Dispersal D Evapotranspiration D Wastewater Pond I D Sand Filter o Other Water Source & Type OWen I 0 Spring I D Stream
or Creek I C Cistern D Community Water System Name Effluent Wil! Effluent be discharged directfy Into waters of the State? [] Yes o No
C::~RnFICATION Applicant acknowledges that the com pleteness of the appl!cation is conditional upon such further mandatory and additional test and reports as may be required by the local.
health department to be made and furnished by the applicant or by the local health department for purposed of the evaluation of the application; and the issuance of the permit is subject
to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and reports submitted herewith and required to be submitted by the
applicant are or will be represented to be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of health in evaluating the
same for purposes of issuing the permit applied for herein. I further understand that any falsification or misrepresentation may result in the denial of the application or revocation
of any permit granted based upon said application and legal act ion for perjury as provided by law. I hereby acknowledge that I have read and understand the Notice and Certification
above as well as have provided the required information which is correct and accurate to the best of my knowledge. C~(,d .. ,> ;;;/5(!lQ~f" c&u.a... 1?~~ Property Owner Print and Sign
Date DATE