HomeMy WebLinkAboutApplication.pdfGarfield County
G ~1 ,f""I I.Ji JI iPP 'P.~l\~ity ~evelopment Department
'\~~-·/\_; ~:1.i j V !1J }08 8 Street, Suite 401
G enwood Springs, CO 81601
JU N 2 8 Z014 (970) 945-8212
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
GA www.garfield-county.com
t\FIELD CO UNTY
·\lM U N I T .1-+.'F-'c ~Hl-'l'J!H\I+------------------------------~
TYPE... STRUCTION
D Alteration Repair
Dwelling D Transient Use D Comm/Industrial D Non-Domestic
D Other Describe ____________________________ _
INVOLVED PARTIES
Property Owner : -'-'---+-"--i.-"-!:::ll'....<....!.-''-""-'-=:.11...:....i....L..!...~Cl.,.L""-'-..,.,....~--Phone: '-'--'-=---~""""""--...._~--l
Mailing Address : __.jL/-~:.L_J,,o:::r::2~:::1::!::::'.'ld:U~~!.:'2l-!...=::~:._ ____________ _
Mailing Address:-------------------------------
Engineer: """"'...,__,........__,_"-'-' ......... ""'-'L...>.;.1-.i....u..-"--'"""""4-"L..L>.~,,L-----Phone: ( ___ --------
Mailing Address:-------------------------------
Job Address: --+.-../....L<~..i...___i..~-""--"'--+--+--#-.1.o<k~-+-=~-_.i........::...us...,1+4-uµ:;..::!...::....t.......J~-...=1.::.....:si<:--...,(...L~
Assessor's Parcel Number: ~328'30&213 Sub .(.~(\ °"fLLl~e Block .8__
Building or Service Type: #Bedrooms: ~ Garbage GrinderM
Distance to Nearest Community Sewer System:--------------------
Was an effort made to connect to the Community Sewer System:-------------
Type oflSDS eptic Tank D Aeration Plant D Vault D Vault Privy D Composting Toilet
D Recycling, Potable Use D Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet D Other _______________ _
Ground Conditions Depth to 1'1 Ground water table ____ _ Percent Ground Slope _____ _
Final Disposal by Absorption trench, Bed or Pit D Underground Dispersal D Above Ground Dispersal
D Evapotranspiration D Wastewater Pond D Sand Filter
D Other ________________________ _
Water Source & Type D Well D Spring D Stream or Creek D Cistern
D Community Water System Name ________________ _
Effluent Will Effluent be discharged directly into waters of the State? D Yes D 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
nece ssa ry 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 issu ing the permit appl ie d 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.
+~12,)1;4/~ 6 -(}/ --;JG!f
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Perk Fee: Total Fees: ~ 3 . OJl.
Fees Paid : 00
\b 'l-3.-
Building Permit Septic Permit: Issue Date: Balance Due : .to . co
DATE