HomeMy WebLinkAboutApplication.pdf.~ ,r--P<jAbsorption trench, Bed or Pit ( )Wastewater pond 108lf" Street, Suite 401, Glenwood Springs. CO 8160J Ph:970-945-8212 Fx:970-384-3440 Illspectioll LiIl<:888-868-5306 www. ga
rn c ld ~cO lll1l y .com SEPTIC PERMIT APPLICATION ( )WELL Percent Ground Slope )Vaull )Pit Pnvy ( )Vaull Pnvy ( )Incineralion Toilet )Composting Toilet )Chemical Toilet S-") -a '"'7
~I _. ~ 1-( )Underground Dispersal ( )Other-Describe )Above Ground Dispersal ( )Evapotranspiration ( )Sand filler directly Into waters the state? upon as may i the local health to be
made and furnished by the applicant or by the local health department f()( purposed of the evaluation of the applicatioo; and the issuance of the permit is subject to such terms and
oonditions as deemed necessary to insure compliance with rules and regulaUons 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 be relied on by Ihe local of health in evaluating the same for purposes of issuing the permit applied
for herein, I further may resull in the denial of the application or revocation of any permit granted based upon sakl application STAFF USE ONLY Pel'mit Fee: gt1 Perk Fee: Total fees:
Fees Paid: tJ() Balance due: 7'3 . ENt; 7"3, ----€:3-' Building Permit: Septic Permit: Issue Date: p';LY)r: -;;(&>'-I-tJ-PifT -'O<lp4-') 2LngDep,: , '" ~ .. , ~~ ~ /tY//ZAPPROVAL /XlATE