HomeMy WebLinkAboutApplication.pdfc4 Gar/reid County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 94S-8212 www.garfield-county.com TYPE OF CONSTRUCTION --INDIVIDUAL SEWAGE
DISPOSAL SYSTEM (1505) PERMIT APPLICATION .... . • • New Installation 10 Alteration I 0 Repair WASTE TVPE . . .. .. • Dwelling I 0 Transient Use 10 Comm/lndustrial 10 Non-Domestic o
Other Describe --_. ... --. .... INVOLVED PARTIE=-S ---'-__. _.. _ . -----'---.~-"--''-'-___':c=----'c-~c-=::_=~~-j;1 I Property Owner: B~ent and Cara Maiolo Phone: (~)369-6625 I Mailing
Address: PO Box 895 Carbondale, CO 8162~ , c-: . . ._. -i Contractor: Brent Maiolo (Home Owner Build) Phone: (~) 369·6625 I Mailing Address: PO Box 895 Carbondale, CO 81623 I, i , fe,;g;;;-eer:
------1 Phone: ( __ ) Mailing Address: PROJECT NAME AND LOCATION ......... ; .... . ... ' .... . "': .. Job Address: TRn M .. "" AVA r:" I r:O A1 R?~ Assessor's Parcel Number: 2393-283-03011
Sub. Lot 28-32 Block. :3 Building or Service Type: Residential #Bedrooms: 2 Garbage Grinder _1_ Distance to Nearest Community Sewer System: N/A Was an effort made to connect to the Community
Sewer System: Type of IS OS • Septic Tank I 0 Aeration Plant I 0 Vault I 0 Vault Privy I 0 COmpostl"g Toilet D Recycling, Potable Use [] Recycling J [] Pit Privy J [] Incineration Toilet
o Chemical Toilet o Other Ground Conditions Depth to 1$ Ground water table I Percent Ground Slope Final Disposal by • Absorption trench, Bed or Pit J D Underground Dispersal I [J Above
Ground Dispersal [] Evapotranspiration o Wastewater Pond I [] Sand Filter o Other Water Source & Type • Well I 0 spring I 0 Stream or Creek I [] Cistern o Community Water System Name
==I -=:;----Effluent Will Effluent be discharged directly Into waters of the State? DYes • No I
) 1 <(!~RTIFICATIOIiII "t~~, . -; . .';-:. ')\_\\'·!i.bE2;J)~;;.L,;~·r ~:j Applicant acknowledges that the completeness 01 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 have provided the required information which is correct and accurate to the best of my knowledge. Brent and Cara Maiolo
7/9/13 Special Conditions: Permit Fee: 1.3 perkFee:~ &/V~. Total Fees: QQ.-$ 73. Fees Paid: ~ ~:=t~ BUil~l " Permit BLll.t-~ql.3 Issue Date: d~h' /'-> BlDGDIV: 'vv 7~ APPROVAL