HomeMy WebLinkAboutApplicationGarfield County
llE(l\' lV .J ri'l munity Development Department
l'\ fJ i . ,.., v" ... 1 eta, .)I.All~ 401
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
· · --· · -·-·flSDS}------------------
Glenwood Springs, CO 81601
JUL 0 9 1014 (970} 945-8212 PERMIT APPLICATION
G:NRfllB\Dl t())UNil Y: www.garfield-countv.com
:.immumm-w 1niaH«JWM1£NT
0 New Installation D Alteration ...... --·-··
'WASTE TYPE
-··ao;;i~--------·or~~e-nt u ~-~-==-o -Com-~/~ndu~-tr-ia-,-_-_-__ -_-_ --0--N-o-n--D-o-me-st_ic ___ _
' n ()thi>r ~ .. ~rri\:l 'i'·
1-INVOLVEDPARTIES 1~ \:1i_~(CA. ~/.....
Property Owner: VLJ 11HiO -:__£._-. -( L2!:Q 0
. Malling Address : {p (q f~o Jl;k( =2J;5
_~h~r -AnL(±true f-.:ewer4 =:Dra.-L~.n
Phone: fh1 ) t/Z~'flJ
·~l/±1 Co B !&SZ.
Pho~e~ (9 1 D --) -915-0 -;:o t z ?·I
'. MaitrngAddress :_,P'--"-D-=&J=· "'-<-.lX~-------------------
Engineer:-------------------Phone:( __ ) ______ _
;'.~ailing Address:------------------------------
Building or Service Type: ----------N-J ~drooms: --=--Garbage Grinder J.l.
Oistance to Nearest Community Sewer System: _ __._ _ __.__ .... 11_._ _____________ _
, Was an effort made to connect to the Community Sewer System: -------------
j 'fype of lSDS
l
Grn11nn C:nnnitinn~
f-mar 01sposa1 t>y
1 Effluent
\ro,_Q..-\-
~ l ()...,-+ :t:l (
\t.Cor~ -ti:
I Septl~-Tank D Aeration Plant D Vault D Vault Privy D Composting Toilet
-------------------·-------------------· -------D ChemlcalToilet D Other _______________ _
Depth. to 1' Ground water table ___ _ Percent Ground Slope ------
0 Abso rption trench, Bed or Pit D Underground Dispersal D Above Ground Dlspersal
-------------------------------0 Evapotranspiration 0 Wastewater Pond 0 Sand Filter
0. Other _______________________ _
M M,. ....... _
D Community Wate r System Name ________________ _
-------------------------------·· ·-·-----------------···---··-15'·---
Will Effluent be discharged directly Into waters of the State? D Yes ~No
/2a n qz w
CERTIFf CA TfON
l\pplicantacl<.nowledges 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 rrealth in eva~uatfrrg the same for purposes of issumg the permn app~}ed for here~n. ~
· 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
ha\le provided the required Information whkh is correct and accurate to the best of my knowledge.
t)J...__._i _I ~f_,i.._~_d_c_._?i.._l<__.o ........ !l.__.o_p'-----'W~J/Jd~~c.._~ 7 ,_Cf,,.. :i ol l/
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Spedal Cond\tions:
~mitFee:~
1<. .
Total Fees:
<::b
Fe~~ Paid: dJ
~;;t. -:-
1 •LDGDIV'
APPROV