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HomeMy WebLinkAboutApplication.pdfGarfield Couni#y F(1Ewptimunity Development Department • � 108 8th Street, Suite 401 Glenwood Springs, CO 81601 JUL 1 5 2014 (970) 945-s212 'kRFIELD COUNTY wtivw,, arfield-county.cc r 'AMITY DEVE1.O.ME_..__.._^_ TYPE OF CONSTRUCTION New Installation • WASTE TYPE VAT., Dwelling j 0 Transient Use 1 0 Other Describe INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PERMIT APPLICATION 0 Alteration ❑ Repair ` ❑ Comm/Industrial ❑ Non -Domestic INVOLVED PARTIES Property Owner:<'L b' , E /6 ,1 / s,d k Mailing Address: ail/AviV,p 3 gv� Contractor:hone: (gxd-1044) 6001 z�©I Mailing Address: ,q90 Cur urki RcT Pgrickch liiti d I4.0.15f Phone: 49i J7 f f .....-" i/ Engineer: Phone: Mailing Address: PROJECT NAME AND LOCATION p-471 Job Address: -5. f 6/ 5, +4. Assessor's Parcel Number: Sub. Building or Service Type: ; M #IBedrooms: . ti Distance to Nearest Community Sewer System: 4 AL-3,245— Building y 3 - Lot — Block Garbage Grinder Was an effort made to connect to the Community Sewer System: No o Type of ISDS Ground Conditions Final Disposal by Septic'tank ❑ Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet Cl Recycling, Rotabte Use 0 Recycling 0 Pit Privy 0 Incineration Toilet 0 Chemical Toilet 0 Other Depth to e Ground water table Percent Ground Slope C in ,5c..1 F Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal 0 Evapotranspiration 0 Wastewater Pond 0 Sand Filter p Other _..ater _..._Source & Type KWe)t ` 0 Spring _ ? 0 Stream or Creek i ❑ Community Water System Name Villa Effluent be discharged directly into waters of the State? ❑Yes Ne rE—ff uent 0 Cistern 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 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 1 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. Oae,,tefir DMA VIVS . Property Owner Print add Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: -3-UD Perk Fee: 00.00 Total Fees: I 3-t5 Fees Paid: 173 00 Building Permit Septic Permit s cpr- 3 ZZ° Issue Date: Balance Due; /85. BLDG DIV: (A-1441,0*0-- 'Ty i c— r"t- APPROVAL DATE ()al . c-7-3 at J Ion -- is- i