HomeMy WebLinkAboutApplicationCommunity Development Department
- -^te 108 8th Street, Suite 401
APR 2 6 tulb Glenwood springs, co 81601
(9701 94s-8212
www.ga rfi eld-cou ntY,com
INVOLVED PARTIES
Property Owner:
MailingAddress: fd b Slto
Contractor:
Mailing Address:
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iMairingAddress: O04 zuCL?on{ P-ptC&N)Are tCo BtuZn :
PROJECT NAME AND IOCATION
Job Address:
Assessorrs parcetNumber: s"a.flUNb FN'lC!!_bt 25 ere,c*
Buitding or Service Typet FEql%G- #Bedrooms: + Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: NO
Final Disposal by
Water Source & Type
.E oye_ll'rne y !,Igglent Use
E other Describe
TyG;iOwfa ifisepticrank i E AerationPlant ] Et vault
j El Chemical Toilet I tr other
Groundconditionsioepttrto1.tGroundwatertable-PercentGroundSlope
tr Absorpiion trench, Bed or Pit I E underground Dispersal , EI nbore Ground Dispersal
,
, tr iripotrrnspiration
i
tr wastewater Pond , E Sand Filter i
i
-- L -- '
Effluent
- i wrii'irrl;;rtue oiiit iii"a aiieiui i"i. *"ieii oiin" st"t"i tr i;; E G .--
1I
ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPTICATION
TYPE OF CONSTRUCTION
"EI ttte* lnstallation i EI Alteration tr Repair
WASTE TYPE
Phone: ( )
E other
-Efweil : tr spring | tr streamorCreek i E Cistern
.8. community water systemrNi ^; qqACiN 6- FNA* - - - -
- -
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, CERTTFTCATTON.,,,,,,,,,,,..,,..,,-,-,-,,-,,,,,,,,,,,
lApplicantacknowledgesthatthecompletenessof theapplicationira;a;tion;ip;;;r;nf,;:li:r:'i"-''rr'l
I niinOatorv and addiiional test and reports as may be required by the local health department to be
.
lmadeand'furnishedbytheapplicantbrbytheloialhealthdepartmentforpurposedoftheevaluation l
i of tfre application; ancjthe isiuance of the permit is subjectto such terms and conditions as deemed ,
I ,"i"irilv io iniui".orpiiance with rules ind regulations made, information and reports submitted
i herewith'and required t6 be submitted by the applicant are or will be represented to be true and a
I correct to theb.estof my knowledge.and belieJ and are designed to be relied on by the,local
i
I ;;ilrtr;rt of health in'evaluatinfithe same for purposes oT issuing the permit applied for herein. I .
lfuitr,erunderstandthatanyfalsifiiationormisrepresentationmayresultinthedenialofthe
I application or revocation of any permit granted based upon said application and legal action for perjury
i
I ai'Rrovided by law.
it-.--
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 best of my knowledge.the
+ffi;bhe,.ar
Property Owner Print and Sign
'#2oolo ,+l?tcll1
Date
Special Conditions:
Permit Fee:
l'l,b.bo
Perk Fee:.-Total Fees:
lL7.Do
Fees Paid:
l2.r.W
Buildinp Permit
stfig- N+q
SeDtic Permit:
frfrr\t+l
lssue Date:5-?r I (z Barante
?l:
J\,.A'.-X-c s-n.201/-''-1 \r- Gappnova[ , DATE
7b,00 o
OFFICIAL USE ONLY