HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8'F' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
Corm- 37q 2757-
i3uUI4ING
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
TY?E OF CONSTRUCTION
• New Installation 0 Alteration
WASTE TYPE
❑ Dwjling-----r 0 Transient Use 0 Comm/Industrial Non -Domestic
I'Other Describe .'vI4LL. cg=Fia • . `1DILET4' SINK
❑ Repair
INVOLVED PARTIES
Property Owner:.. "i E- Ft..t�,S LLC. Phone: ((7O) qq • j
Mailing Address: re, 6D J30 Vi i% OP S5
Contractor: D GOA! rrameriork.r Phone: (1 170
Mailing Address: 'O 60% MO ai..E14!WDt 5P(II4 S LOt_in $1,602
Engineer: 5D EWQ-/NEri2Uu4- Phone:(Cf"!O )'7n(/O3Ie
Mailing Address: 5b2- "Pil/V Si SCUT A 3 CARBONDAIAI Cd. W23
PROJECT NAME AND LOCATION
Job Address: r ' Cil►/ RO /
Assessor's Parcel NumberZl$52:714000$ Sub. Lot Block
Building or Service Type: Zp t X 2?' or-Fic.E #Bedrooms: ® Garbage Grinder t
Distance to Nearest Community Sewer System: /SU?*
Was an effort made to connect to the Community Sewer System: NO
ErSeptic Tank 0 Aeration Plant 0 Vault 0 Vault Privy I 0 Composting Toilet
Type of ISDS
Ground Conditions
O Recycling, Potable Use
O Chemical Toilet
O Recycling
0 Pit Privy
❑ Indneration Toilet
0 Other P24T-i70-/7i"/Eho
Depth to 1' Ground water table 100'
Percent Ground Slope 411 4
Final Disposal by
I'Absorption trench, Bed or Pit 0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond
Ir Sand Filter
O Other
Water Source & Type
Effluent
O Well
0 Spring
0 Stream or Creek 1 0 Cistern
O Community Water System Name CITY OF
k)000 $PR4HC J
Will Effluent be discharged directly into waters of the State? 0 Yes pro
CERTIFICATION
Applicant acknowledges t at the completeness of the application is conditiona 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 informa of wham's core and accurate to the best of my knowledge.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY•
Spedal Conditions:
/t.v/ !o
,i.rcis3 -
JUTi(2"
3,1eiL_Fiti�)
Permit Fee: 123
Perk Fee:
Total Fees 3
Fees Paid: ma,.
Building Permit
e it:
L
R�c124)110
Issue D
t40 ( (-ot
Balance Due:
—tr.
BLDG DIV: �� Rf
iF
1tel
// /
I
APPROVAL
•
i
DATE
p' {�3 f, i% (p 49 0, RIP -111149