HomeMy WebLinkAboutApplication.pdfc:G Garfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-countv.com INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS)
PERMIT APPLICATION TYI3E OF CONSTRUCTION G1I' New Installation 10 Alteration 1 0 Repair WASTE TYPE 'Q76welling 1 0 Transient Use 10 Comm/lndustrial 10 Non-Domestic o Other Describe INVOLVED
PARTIES ~ ~ pro~.erty Owner: \ bloK::5A~n\ ~t k Phone:~Jcnq[fkf~(Q Cf MaIling Address: do: . Co I . . I Contractor: I rou \ W C' \ Cl\ le Phone: f:DD ) .3C8 --q 'f'll~ • Mailing Address:
Engineer: Kqtc U)-~\\~ . ~p~e:ffL{~) Mailing Address : ()b1 \ ' ~!b. \\c1, 'bL &} _ ~ ~ ~ ~~41 PROJECT NAME AND LOCATION \ -~-Ad-t\:: Job Address: ~ 'J \."\ 01 V) \. 0 1.11'1 U .:....
Assessor's Parcel Number.: I ~~I~~bsu~bnS;lk &'~\inl) lot ~ Block --Building or Service Type: "'% ~(1 #Bedrooms: 3 Garbage Grinder D Distance to Nearest Community Sewer System: \, ~
N\\C' Was an effort made to conn'}t to the Community Sewer System: hl'O ~ Type oflSDS [¥Septic Tank I 0 Aeration Plant I 0 Vault .1. 0 Vault Privy I 0 Composting Toilet o Recycling,
Potable Use o Recycling I 0 Pit Privy I 0 Incineration Toilet o Chemical Toilet o Other Ground Conditions Dep~o 1n Ground water table I Percent Ground Slope Final Disposal by ijY Absorption
trench, Bed or Pit I 0 Underground Dispersal I 0 Above Ground Dispersal o Evapotranspiration o Wastewater Pond I 0 Sand Filter DO,. Water Source & Type UVWeU 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? DYes ~' No
CERTIFICATION Applicant acknowledges that the completeness of the 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 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 action for perjury as provided by law. I hereby acknowledge that I have read and understand the Notice and Certification above
as well as d accurate to the best of my knowledge. 1 D --\ -,;,JD\ 3 Date OFFICIAL USE ONLY Special Conditions: P~~.QQ-Perk Fee:OO 1$ D. ~ Total Fee~ ~73-Fees Paid: 00 '675'-~ding Permit
Septic Permit: ~ Issue Date: {' ~ ,..,if3 \D-IS-l3 plQ."aL l' ~ \ -~ h ctf -:--I S-)y,13 BLDG DIV: APP~VAl r "-DATE \ ./-\ a · \S· ~