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3çrr '\{ù nity Development Department
lo8 8th street, Suite 401
Glenwood Springs, CO 81601
(970194s-82t2
www.sarf¡eld-countv.com
Gaffield County INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(tsDs)
PERMIT APPLICATION
.TYPE OF CONSTRT'CTION
New lnstallation tr Alteration tr Repair
WASTE WPE
( Dwelling E Transient Use tr Comm/lndustrial tr Non-Domestic
E other Describe
INVOTVED PARTIES
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Address: t"? t26 -Tree l.-au:n Þr A
Phone: (_)Property Owner:
Mailing
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Phone:
Mailing Address:
Contractor:
Was an effort made to connect to the Community Sewer System:
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+
Phone: ( )
Garbage erinder !þ
PriileCrkfcIaþ^2 I Lot Block46r:-ôI3,INumbercel
Engineer:
Distance to Nearest Community Sewer System:
Mailing Address:
Building or Service Type:#Bedrooms:
PROJECT NAME AND LOCATION
Job Address:
Assessoy's Pa
El vault E Vault erivy tr Compost¡ng To¡letSeptic Tank E Aeration Plant
E Recycling, Potable Use E Recycling E Pit Pr¡w E Incineration Toilet
E Chemical Toilet E other
Type of ISDS
Percent Ground SlopeGround Conditions \Depth
to 1"'Ground water table
E Above Ground DispersalAbsorpt¡on trench, Bed or Pit E Underground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
Final Disposal by
E other
E Cistern\wett E spring El Stream or CreekWater Source & Type
E tommunity Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes E ltlo
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I hereby acknowledçthat I ha¡e read and undersand the Notice a¡d Grtificdion above æwell as
have provided the required information whidt is corred and am.¡rate to the be* of my knowledç.
John H. McC
Ffoperty Orvner Êint md
7,Ll.bo I IoÇlt-, b ?o /l
c June 8.201
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Total Fees.00
BdanæDue:lsseDate.Sptichrmit:
-4
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