HomeMy WebLinkAboutApplication.pdfc::e; Garfield County ~.: E C EN V ' o~unity Development Department .[\'). 1.J JU 108 8th Street, Suite 401 INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1505) Glenwood Springs, CD 81601 DEC 3
0 2013 (970) 945-8212 PERMIT APPLICATION GAHFIELO COUNTY www.garfield-county.com iMUNITY orv. q nPMENT TYJE OF CONSTRUCTION J2t New Installation 10 Alteration 1 o Repair WASTE TYPE .M
Dwelling 1 0 Transient Use 1 0 Comm/lndustrial 10 Non-Domestic o Other Describe INVOLVED PARTIES Property Owner: \'ull-I\ '" ,O!'l I-lo.DIN6~ I£:{ Phone: ( 'lTD ) Mailing Address: 32"/Nl~,""
51'". C4.<tB.' '''O ~ct; 0 > lll~ ~.l Contractor: 5"orr I(.£. '-I Phone: ( G(~ ) )'11. -1501 Mailing Address: 332~ S , Dv ,H"l.t. wilry I AvR,o(tA Co 6'0'::"3 Engineer: r K~LL.A<l ~"'(,I"'f(IlS
:IN C. Phone: (~) ~B -3~d Mailing Address: PRO~ECT NAME AND LOCATION Job Address: ::32't PvIlJ\-"'DI\ R.I't",cd \l-Oll-P Assessor's Parcel Number: 2~J,3 -,"/II~"'l Sub. I:!"E ..... JAU-e,
Rtwcl! Lot %0 Bloc kV~ Building or Service Type: #Bedrooms: Garbage Grinder_ Distance to Nearest Community Sewer System: Was an effort made to connect to the Community Sewer System:
/Type of IS OS JfJ Septic Tank I D Aeration Plant I 0 Vault I D Vault Privy I D Composting Toilet o Recycling, Potable Use o Recycling I D Pit Privy I 0 Incineration Toilet o Chemical
Toilet o Other Ground Conditions Depth to 15 Ground water table 'F(!-~'L.:i I Percent Ground Slope Final Disposal by o Absorption trench, Bed or Pit I 0 Underground Dispersal I 0 Above
Ground Dispersal o Evapotranspiration o Wastewater Pond I 0 Sand Filter o Other Water Source & Type fi!J Well _10 Spring J 0 Stream or Creek J 0 Cistern o Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? DYes }1L 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 su
bject 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 sa id 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. (/~MI~LN'../1I/iPlI.f-AIS11nIlV_ .4I.<).--=.3.." "'_--''.'J'-_____
Date OFFICIAL USE ONLY Special Conditions: Permit Fee: '7'3. (J!)-Perk Fee: [Nt; Total Fees: l/> 7?...) 20 F~1~~: 0C) -"6 .---r&i~er~~9 Septic Permit: 0E?T-'¢e>AA ra~~,L\ ~(r~e: BLDG
DIV: 4;~~~~ ~ 0z-fr'f APPROVAL DATE 7 ... O· O· l''S