HomeMy WebLinkAboutApplicationEGarfield County
JUL 111017 Community Development Department
GARFIELD CCN T Y. 108 8th Street, Suite 401
)MMUNI IY NVCLOPMENT Glenwood Springs, CO 81601
(970) 945-8212
TYPE OF CONSTRUCTION
New Installation ❑ Alteration ❑ Repair
WASTE TYPE
0 Dwelling ; ❑ Transient Use ❑ Comm./Industrial ; ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: iZ6La n- pG 1t'/jCif 11 C Phone: (170) (v -_Y0 8330
Mailing Address: 637 Z5 Kil C;I &Z7
Email Address: efO434 CO
Contractor: Phone: I
Mailing Address:
Email Address:
Engineer: ca OSS jx►�qe_r WZ64� Phone:
Mailing Address: ISL !'4l:�_, _-
Email Address: nt+�Qi un Q . G
PROJECT NAME AND LOCATION
Job Address: lQ_j4_-_Z3 _ JQQ A r� S a �, +){ Cp%O,-Y d o
Assessor's Parcel Number: 2191, 043 •0- 0�s� 1J� 2
_ ub. �iiPi � f Oh '�I�.. 0LOt y3 Block
Building or Service Type:IG.� o ��.,, 1113edrooms: Garbage Disposal(Y/N)
r
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Septic Tank ❑ Aeration Plant ❑ Vault ❑ Vault Privy I Composting Toilet
❑ Recycling, Potable Use ❑ Recycling ! ❑ Pit Privy ; ❑ Incineration Toilet
❑ Chemical Toilet ❑ Other
Depth to 15' Ground water table 7 _ Percent Ground Slope
Absorption trench, Bed or Pit ' ❑ Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration ❑ Wastewater Pond ❑ Sand Filter
❑ Other
Water Source & Type Well ❑ Spring ` ❑ Stream or Creek
❑ Community Water System dame
❑ Cistern
Effluent Will Effluent be discharged directly Into waters of the State? ❑ Yes A 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 aid wdefstand the Notice and C"tificathm aboae as well as
have provi4o the required information which is correct and accurate to the best of my knowledge.
PtQpefty Owner Print and Sign
7-11 - 17
ago
OFFICIAL USE ONLY
Special Conditions:
Permit Fele: Perk Fee: Total Fees: I�
Fees Paid: I�
Building Permit
Septic Permit:
Issue Date:
Balance Due:
'LIS 19
SC - 4492Z
-
4**
BUILDING/ PLANNING DIVISION: -4
-r7
Signed Approval
Date
PD • I Z3 • olv� C �� �- I I I �'