HomeMy WebLinkAboutApplication.pdfc:E' Garfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1505)
PERMIT APPLICATION I )JPE OF CONSTRUCTION New Installation 10 Alteration I o Repair WASTE TYPE IliD Dwelling I 0 Transient Use 10 Commjlndustrial 10 Non-Domestic o Other Describe INVOLVED
PARTIES Property Owner: Phone: ( ) Mailing Address: Contractor: W,J./V If' fL/Phone: ( ) Mailing Address: Engineer: Phone: ( ) Mailing Address: PROJECT NAME AND LOCATION , Job Address:
'!iOl"lle. liOVlCU'\ C L~U.'1lJ J,() UJ,<) , Assessor's Parcel Number: frllll 03Lj -co-SdO Sub1VIltJOQ3? ~ O\l'{11\ ~\If(no~~ Block __ Building or Service Type: Ql \U(l\\VI ~ #Bedrooms:
:) Garbage GrinderlSD Distance to Nearest Community Sewer System: 5 /VIA.1 \:s, Was an effort made to connect to the Community Sewer System: ~~ \ Type oflSDS ...Q' Septic Tank I 0 Aeration
Plant I 0 Vault I 0 Vault Privy I 0 Composting Toilet o Recycling, Potable Use o Recycling I 0 Pit Privy I 0 Incineration Toilet o Chemical Toilet 0 Other Ground Conditions Depth to
151 Ground water table I Percent Ground Slope Final Disposalliy o Absorption trench, Bed or Pit ! If Underground Dispersal I 0 Above Ground Dispersal o Evapotranspiration o Wastewater
Pond I 0 Sand Filter o Other Water Source & Type a Well I 0 Spring I 0 Stream or Creek I 0 Cistern o Community Water System Name Effluent Will Effluent be discharged directly into waters
of the State? o Ves ft-No
\, CERTIFICATION Applicant acknowledges that the completeness ofthe application 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 compl iance 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 issu ing 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 action 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. Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions:
Pf~".§Q. Pl"'rk Fee ~ !. ENG. "{.ota\ F~es <:i F .... c Paid: \$+,3.-,1)=13. -I~i.l -di:ng~ pe r~q,<:.q. ... ~S~RptPic Tpe-rm;} Q5~)A. Issue Date: B1>~. ~. e: d..g L. ~ /,p~~:J BLDG
DIV: APPROVAL 6AT€" ~ . 1-·13