HomeMy WebLinkAboutApplicationc:G · Garfield County
Community Development Department
108 stti Street, Suite 401
Glenwood Springs, CO 81601
(970) 945·8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
l5Cf' New Installation I D Alteration I 0 Repair
WASTE TYPE
Gil Dwelling I a Transient Use I D Comm/Industrial I Non-Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: Do.@ c. ·" r<a .m m--i ~ . Yoi t n ~
Mailing Address: .P. o · B 0 x 3'100 Ca,.~\'= , C..o
Phone: (q , o )--'4 _.,;.__-..,-........,it:
s ) lo 3 /
Contractor: ~~uc;:.......,;:_;_::c:;.:=..:.=._.11&....o-L,l~~1-----Phone: Fl-,0 ) (t J l • S C. 1 ?-
I Mailing Address: )Ci 3:z BC) , £Cl.f\ l t:" , C D SJ<-~J
Engfneer: ....-~:..:....;;...._~c..:..:illliif.::::~....:..~~~------Phone: _-r ...... o_, ..... 9._4 .... 9 ..... _._.q _..3_°1_._· _, _
Mailing Address: :P. 0. iS.o )':. "I~-,~ VQ.; 1
1
Co ~It.. 5 ~ ..__ ______ _
PROJECT NAME AND LOCATION
Job Address: -..:a."-11:~1..w--6.,;.LJ.......i..r.LJ.~~~....J::::...:;:i~--~""""'-!i'-';;...J:.tS..~.1.....1:;;,s;;;;..i:::i..-:;;::::~
c:rv'c:M. ~ ..p
Assessor's Parcel Number:"l~d<? lo 'too&> S .-..:..:.. ______ Lot J Block __
Building or Service Type: R es 1 dc:o-ho'..L #Bedrooms: l.J. t I Garbage Grinder J_
Distance to Nearest Community Sewer System: ..... 5"--rn ........ · .... 1 ..... 1 ... e"""s ___ ~-~---------
Was an effort made to connect to the Community Sewer System: ,..,J....,.C"> __________ _
TypeoflSDS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank C Aeration Plant C Vau~ _.:' Va;,l~Pri;y ca= Composting Toilet .
C Recycling, Potable Use C Recycllng D Pit Privy D lndneratlon Toilet
C Chemical Toilet C Other ______________ _
Depth to i Ground water tab~CS:~ [ Percent Ground Slope _ ----i
Absorption trench, Bed or Pit I C Underground Dispersal : C Above Ground Dispersal
•
C Evapotransplratlon C Wastewater Pond j C Sand Filter-
C Other ______________________ _
Well C Stream or Creek c astern
a Community Water System Name _.AO ........ LS.= .... --~--------------
Wlll Effluent be discharged directly Into waters of the State? C Yes ~No
------~---------------------------. CERTIFICATION
Applicant ac now edges t at the completeness o t e app ication 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 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 Sign
OFFICIAL USE ONLY
Special Conditions: ...oe51~ ,v FofL
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Date