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HomeMy WebLinkAboutApplicationAEGarfield County Community Development Department 1088 1h Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com TYPE OF CONSTRUCTION W New Installation WASTE TYPE (a Dwelling ❑ Other Describe ❑ Transient Use ❑ Alteration ❑ ❑ Comm/Industrial ❑ Non -Domestic INVOLVED PARTIES Property Owner: Phone:( 1116 �-S I Mailing Address: �� ? 1 2 3 RA C`_:T . t(iii FS 15'6 Contractor: _ T R A,U� e.lo_�F[ ri4 Phone: (7>! q )_ S'a - S_ MailingAddress:_Q O (_�j-Rar Engineer: PE Phone: (31_) Mailing Address: SSS' Rio Os_Q Lar.&_ 61, e.0 g Sinq PROJECT NAME AND LOCATION _ Job Address: Assessor's Parcel Number: MD y3 S 9 bo;XX Sub. Lot Block Building or Service Type: _ R e,5, #Bedrooms: �� Garbage Grinder Distance to Nearest Community Sewer System: i b Kin ti k t,.,S Was an effort made to connect to the Community Sewer System: _ h 0 Type of OWTS Septic Tank ❑ Aeration Plant ❑ Vault ❑ Vault Privy ❑ Composting Toilet i i ❑ Recycling, Potable Use ❑ Recycling I ❑ Pit Privy l ❑ Incineration Toilet ❑ Chemical Toilet ❑ Other Ground Conditions Depth to 15 Ground water table 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 4 Well ❑ Spring ❑ Stream or Creek ❑ Cistern ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? ❑ Yes RI No i[aI�:i�I� _• � 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 and understand the Notice and Certification above as well as have rove a the r quired information which is correct and accurate to the best of my knowledge. ---- - (? - / '/7 Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: Perk F e: Tot I Fees: Fee Paid: ©d Balance Dyne: Building Permit (� 5eptit Permit: QQ Issue Date: BLDG DIV: APPROVAL DATE