HomeMy WebLinkAboutApplicationGarfield County '
JUL 2U17Community Development Department
108 8t" Street, Suite 401
Gka.If.-i ' ' Glenwood Springs, CO 81601
)MMUNIT1` , _' J970) 945-8212
TYPE OF CONSTRUCTION
PNew Installation
WASTE TYPE
Al Dweiling ❑ Transient Use
❑ Other Describe
❑ Alteration 7
i ❑ Repair
ElComm./industrial ❑ Non -Domestic
INVOLVED PARTIES
Property Owner: Phone: 70 j �'yd " y33
Mailing Address: l0 37 ZS _lec� Ci J L V1 5 _
Email Address:
Contractor: Sarsvt Phone:
Mailing Address:
Email Address:
Engineer:.. G4,0Sia 10- ~��er0n.s�5 �s hone:{q7d j 7,50--3331_
Mailing Address: 6M AtC LL r
the Email Address: C S n n
PROJECT NAME AND LOCATION
Job Address: - _Lof_ 2-$ F'" I'A5, e)^ +i-4_ !o lm r4ACM Svc b 1'v �'S I o'er
Jp
Assessor's Parcel Number: Z-1 = l '041 ' D7 5 b$Q� '3 _o f) ah—[yi°�ot _Z_l' Block
Building or Service Type:#Bedrooms: — Garbage Disposal (Y/N)-Y--
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS Septic Tank ' ❑ Aeration Plant ❑ Vault ❑ Vault Privy Composting Toilet
❑ Recycling, Potable Use ❑ Recycling ' ❑ Pit Privy ❑ Incineration Toilet
r ❑ Chemical Toilet ❑ Other
Ground Conditions Depth to 1.t Ground water table. V l Percent Ground Slope
Final Disposal by Absorption trench, Bed or Pit ❑ Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration ❑ Wastewater Pond ❑ Sand Filter
❑ Other
Water Source & Type Well ❑ Spring ❑ Stream or Creek ❑ Cistern
❑ Community Water System Name
j Effluent Will Effluent be discharged directly Into waters of the State?
❑ Yes
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 hemi ackwwW49 that I hays read- arid- tmderstamd- the Native and Certification above as weft- as
have provided the required information which is correct -and accurate to the-bestof my knowledge.
Prole ner Print and Sign Ion
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
4Q?, W
Perk Fee:
Total Fees:
Fees !d:
Building Permit
Septic Permit:
Issue Date:
Balance Due:
4010419 l7
BUILDING/ PLANNING DIVISION:
Signed Approv I
Date
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