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)MMUNITY DEVELOPMENT
Garfield County
Community Development Department
108 8th areet, Suite 401
Glenwood qprings, 0081601
(970) 945-8212
www.garfield-county.com
N DI VI DUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERM ITAPPLICATION
TYPffi OF CONSTRUCT] ON
Property Owner: G:r,`/ / iw.-4vso,v Phone: (765 3 ) l/�--5---6--) G Ci
Mailing Address:],, - - 44z i (//S Jt�r� i'.� r/� 4uv:-d`
Contractor: poz.i� k,„,„,,,,,, Ofm.S-�VvcJZtr�.k aintp Phone: (1>O) 5.'>k •g> fZ
New Installation
❑
Alteration
0
Repair
WASI STYPE
Job Address: ✓"c``<'e:e 7 3 l,?,rciA
Assessor's Parcel Number:
Building or Service Type:es,,,-
Distance to Nearest Community
Was an effort made to
/
,2 ?973o/32Sub. 6 vua j<///jei,,c.ie.Z Lot Block
izi/ #Bedrooms: 3 Garbage Grinder�o'
Dwelling 0 Transient Use
0 Comm/Industrial
0 Non -Domestic
❑ Other Describe
❑ Vault Privy ❑ Composting Toilet
❑ fecyding, Potable Use
❑ Recyding ❑ Rt Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 11 Ground water table
Ze /
INVOLVED PARA ES
Property Owner: G:r,`/ / iw.-4vso,v Phone: (765 3 ) l/�--5---6--) G Ci
Mailing Address:],, - - 44z i (//S Jt�r� i'.� r/� 4uv:-d`
Contractor: poz.i� k,„,„,,,,,, Ofm.S-�VvcJZtr�.k aintp Phone: (1>O) 5.'>k •g> fZ
Mailing Address: S'Co. /2'%,'ii. 4/ S e 3()tA1 Cal -4-1-1144e /bad
)
Engineer: ai — , .L7( ./-Phone: (--"ye, ), f (5S//
Mailing Address: / EO Z- //// oma, _/ ��f,4„,...e/4Z_. (2 g/ 2J
FRO,ECT NAM E AND LOC411 ON
Job Address: ✓"c``<'e:e 7 3 l,?,rciA
Assessor's Parcel Number:
Building or Service Type:es,,,-
Distance to Nearest Community
Was an effort made to
/
,2 ?973o/32Sub. 6 vua j<///jei,,c.ie.Z Lot Block
izi/ #Bedrooms: 3 Garbage Grinder�o'
Sewer Sjstem: Ljzi,
connect to the Community Sewer System:
�/
Type of ISDS
.12-*ticTank ❑ Aeration Rant ❑ Vault
❑ Vault Privy ❑ Composting Toilet
❑ fecyding, Potable Use
❑ Recyding ❑ Rt Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 11 Ground water table
Ze /
Fbrcent Ground
Sope AV--/ cjn
Final Disposal by
0 Absorption trends, Bed or Fit 0 Underground Dispersal
0 Above C-ound Dispersal
0 Evapotranspiration
0 WastewaterFbnd ❑ 3ind Filter
W her ��'".' o`<i',/ ie.. .moi: k.r,r--<crce4.1r , %a.
......<74,1/42/911,1"/
0 Stream or Creek 0 Qstern
Water Source & Type
0—Well ❑ Spring
❑ Community Water Sjstem
Name
Bfl uent
Will Effluent be discharged directly into waters of the Sate? 0 Yes -
(U
CERT1RCA11ON
Applicant acknowledgesthat the oompleteness of the application isconditional 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 compliancewith 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 bad 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.
Property Owner Print and Sgn
Date
OFR aim.. UfONLY
BDedal Conditions:
Permit Fee: �—
$73,
Fork Fee:
EEC's+
Total Fees:
1-f3.m-
Fees Paid: t
1 ..
Building Fermit
(U--3C)1q
Septic Permit:
5EV\-3 88
Issue Date:
Balance Dug
go.c_.
BLDG DIV:
%�
AFPHJVAL DATE
Td u,.1i •lif
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