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HomeMy WebLinkAboutApplicationI,;,. ,� Garfield County RECEIV mmunity Development Department V 108 8th Street, Suite 401 MAR 23 2018 Glenwood S riri 5-8?C 81601 12 GARFIELD COUNTY. COMMUNITY DEVELOPMENT TYPE OF CONSTRUCTION INDIVIDUAL: SEWA DISPOSAL SYSTEM (1SDS) PERMIT APPLICATION. O New Installation 0 Alteration I WASTE TYPE ■ Dwelling ; 0 Transient Use 0 Comm/Industrial 1 0 Other Describe ■ Repair 0 Non -Domestic INVOLVED PARTIES Property Owner: C d- a • J/.,jj - . hone: [ 97O 61$- 475 Mailir� Address: 0285 c5UAJ J y #v'es Ind . Guw.J. ' jr:Ay,r &Q '/S'/ Contractor. 12lpi ff / r../2 i/� .� � Phone: [ 970 1 984 - .33os3 Mailing Address: /2 t7 ev[ifu Z J, GJe�w,a1 ---/?'1"--.`"1-3/ Co &b0/ Engineer:2Anrt'ln.s fV- /2/42dh 7, /4F'too 165 Phone: { 92b ) 618 2 ex, Mailing Address: /S826, O.. i Ur$ r p hr- l� i.t9 Iji»/S,, 040. Sarco PROJECT NAME AND LOCATION Job Address: !9 2 R3 Scf io c £l ,rc.s Ad.C0 s nl�..+,� 1. o � ' - # s Ary ,/IS tom[// Assessor's Parcel Number: Sub. _sohdriv;SVo.44J Lot fl Block Building or Service Type: mi a e./ % es aigAI .e #Bedrooms: 3 Garbage Grinder Distance to Nearest Community Sewer System: 1. -a -9 -,3 -on ,Uo spuuz yy//){ t.) . ,,9 - 2ja,L-7- Was an effort made to connect to the Community Sewer System: -.Wo re; e -,1-R. /� j Type of ISDS i Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet ❑ Recyding, Potable Use 0 Recycling 0 Pit Privy 0 incineration Toilet O Chemical Toilet 0 Other Ground Conditions Depth to 1" Ground water table? .. dGYti1. Percent Ground Slope ...5/is f Final Disposal by • Absorption trench, Bed or Pit ❑ UDispersal 0 Above Ground Dispersal ❑ - Evapotranspiration ❑ Wastewater Pond ❑ Sand Filter © atter Jjti l i 7'2r�t-a Water Source & Type 0 well 0 spring 0 stream or Creek ▪ Community Water System Name d Effluent will Effluent be discharged directly into waters of the State? ❑ astern 0 Yes ■ 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 De 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. 1 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. herebv acknowledge that 1 have read and understand the Notice and Certification above as well as have provided the required information which is correct and accurate to the best of my knowledge. Property Owner Print and Sign Date 1 OFFICIAL USE ONLY pad 3ia3// 8 . i 1 5 $T. oO Special Conditions: Permit Fee: ..,ek Perk Fee: Total Fees: r" Fees - Building Permit r_� Septic Permit: -~y'�- Issue Dat : l j6 1��� Balance Due: /'9 • ° BLDG DIV: Y A • p' a VAL DATE