HomeMy WebLinkAboutApplication_ . Garfield County
Oammunity Development Department
th
1088 Greet, SLite401
Glenwood Springs, 0081601
(970)945-8212
www.ctarfiel d-cou nty.com
'TYPE OFOONS RJCTION
je New Installation
WASTETYPE
0 Alteration
A` Dwelling 0 Transient Use 0 CbmmJ Industrial
❑ Other Describe
Non -Domestic
INVOLVED PARTIES
Property Owner: # .tk Loll:.. Phone: 3 1p tG 32CV
MailingAddres5 4L -371';"c uS Ni--) `&k.01:?l
Contractor: ' Sc . Phone: ( fit )
Mailing AddresE 3L L( �.. } �n ,�++�� .,.] CC* ( . `glaLI1
Engineer: C -/t -,4'4l0
Mailing Address: ' q °r k.00t 04 S1,3 LtD. $IVO t
Phone: ( q" -LO )
FRD.ST NAM EAND LOCATION
.bb Address: Lkf,; V t . {#,� (J 4 7A,
Atrer" Parcel Number:
Building or Sotvice Type: Q V r1
Lot Block
tiBedrooms: Garbage Grinder
Distance to Nearest aimmunity &wer System:
Was an effort made to conned to the (bmmunity Sinner System:
Type of ONVTS €apticTank ❑ Aeration (Rant 0 Vault 0 Vault Privy 0 QxnpostingToilet
O Fbcyding, Potable Use 0 %cycling ❑ Rt Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to 1ffi Ground water table Percent Ground Sope
Final Disposal by
❑ Absorption trends, Bed or Rt ❑ Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Band Alter
❑ Other
Water Sburoe & Type ❑ Well 0 firing 0 are= or Oeek 0 astern
❑ mmmunity Water System Name
Effluent Will Effluent be discharged directly into waters of the Sate? 0 Yes 0 No
CER 1RG411ON
Applicant acknowled9asthat the completeness 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 applicat ion; 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 ruing 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 thrtification above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
o ert
p y Owner Print and Sgn
is
Date
OFR OAL UgONLY
aDGDIV:
4}edal conditions
Permit Fee:
Iz 3• et)
Perk Fee:
195. tau
Total Fees
a13• be,
Fees Paid:
al -3. Uto
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six- c
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13alanceDueYA
DATE