HomeMy WebLinkAboutApplicationiiærlield CCIurtty
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, eO 81601
(970) 94s-8212
www.Ea d!shLçegn'bLç8{0
E Alteration lr
WASÏE TYPE
fl Transient Use E Comm./lndustrial n Non-Domestic
Describe
INVOTVEÐ PARTIES
Property Owner¡
Mailing Address:
Email Address:
C(¡ntractor:
Ioah -tll i S-*"Phone;,î7o t"p1:Êi+4 -'-
Phone¡
q
lis
Mailing Address:
Email Address:
.o
Phone: f
Mailing Address: _
Email Address: .
PROJECT
Iob Address
Assessor's Parcel Number:'t3 l¡út 'Ç
Building or Service rype: f¿6ift¿,f¡-ir'Ot fiBedrooms: -l-Garbage Di¡posal(Y/Nl A/
Distance to Nearest C.ommunity Sewer System:A
Was an effort made to connect to the Community Sewer System:
Absorption,trench, Bed:or Pit El Above,Ground'Dispersal
,- EI Evapotranspiratíon E Wastewater Pond D Sand Filter
Other
El wel!E Spring El StreamorCreek E Cistern
Community Water System Name
':f,v"e ãt,OflffS p.,Septic,Tank ' ü' Aeration'Plant , El Vault E Vault,Privy
t Recycling, Potable Use D Recycling E Pit Privy tl
A''€hemicâlTo¡iet E Other
CompÒstinB,Tr¡let
Percent Ground Slope s7^Ground Conditions uhl¿&rrsìdv'\Depth to l't Ground water table
Water Source & Type
Will, Effluent be:discharged direetly, ínto watersrof ,the,State?Yes No
Applicant acknowledges that the completeness of the application is conditional Ypgn such further
nìandatory and addit'lonal test and reþorts 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 isiuance 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 f_or 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 Not¡ce and Cert¡fication above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
/n*?,7 _t7
ûrner Print and Sign Date
wt Þ*)w
oFFteHL UsE.S, t!¡tY
Special Conditions:
Total Fees:7-?3-'Fees Paid:
2+7 -Permit Fee:
lzb '-Perk Fee:l(Þ-
lssue Date:?.25-17 Salance Due:
ú
Buildins Permit -
FtzE- 4ÍoS
Seotic Permit: -
5øÞ1'490ç
lztløn
Dâte
BUILDINGI PTANNING DIVISION:
Signed Approval