HomeMy WebLinkAboutApplicationGarfield County
MAR 16 1016
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
al Dwelling L❑ Transient Use
❑ Other Describe
0 Alteration
El Repair
0 Comm/Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: A "E'✓/+'` 4,454-71
Mailing Address: 734 3 c . 1e, 7 3 3
Phone: ( 970 ) 37 :c
5/Li l a. .P// ?`2
Contractor: �' Phone: (
Mailing Address:
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number:
Sub.
Building or Service Type:(o`.+/G�
#Bedrooms: 3
Lot Block ___
Garbage Grinder _
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of ISDS
Pi Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
9 Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions
Final Disposal by
Depth to f Ground water table
Percent Ground Slope
O Absorption trench, Bed or Pit
0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type cifWell 0 Spring 0 Stream or Creek I 0 Cistern
Effluent
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes 0 No
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 I have read and understand the Notice and Certification above as well as
have provided the required informatj which is correct and accurate to the best of my knowledge.
Prdp rty Owner Prir rand Sign
Dat
OFFICIAL USE ONLY - - - __� _ —. -- — -._.-. _ - ..-_ .
Special Conditions: ��
006(14 igici 3 ata0,4zow 3 /?gitty
Permit Fee:
. w
Perk Fee:
Total Fees:
4-s. n
Fees Paid:
9 -C. -DO
Building Permit
Septic Per . i•
i r- oda
Issue ate:
31111 uc93.
Balance Due:
BLDG DIV: - lG -2-0/,
PROVAL DATE
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