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Community Development Department
108 8ü'Street, sulte 401
Glenwood Springs, Cq 31601
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Garfield Coanty
New lnstallation Alteration ERe
Transient Use tr Comm tr Non-Dornestíc
Other Describe
INVOTVED FARTIES:'..,..:..
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Mailing Address:
Email Address:o
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Phone:
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MaillngAddress:
Emall Address:
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Mailing Addreesi -. , ".
Email Address¡
Phone: { IEngineer:
PROJECÍ NAME ITND
rgedrooms¡ ó Garbage o¡sposal{Y/f{} Yt nÀ: (4
Was an effort made to connÊct to the Cornmunif,y Sewer Syste.t N qYfC
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Assessor's Parcel ñlumber:
Building or Service Type:
D¡stânce to Nearest Commun¡ty Sewer System:
Job Address:
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F S€ptrcTånk E Aeradon Plant E Vaulr E Vauh Privy f Compo$lngTo¡let
F Recyclln& Potable Use [I Recyctlng E P¡tPr¡ly E lmineratlon Tdlqt
Type of OWTS
tr Chemlcallo¡lèt E Othar
Ground Condltions Dêpth to 18t Ground water tabla (-e{aPercent Ground Slope
E Absorptlon trencù, Bed or Pit p Underground Dlspersal E Abovs Groünd Dbpersal
E Evapotransplraüon E Wasteu¡eter Pond E Sand Fllter
Final Dlsposal by
E Orher
! wen tr Sprlng lX Strean orCreêk E ctctemWater Source & Type
E Connunity Water gyitçrn Name
Effluent lir¡ll Effluent be dlsùarged dlrectly inro watêrs of the Sfste? E yes F*;
Applicant acknowledges that the completeness of the application is condítional 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 Êvåluation
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 rny 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 revocat¡on of any perm¡t granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and
have provided the required informatlon
the Notlce and Certification above as well as
and accurate to the best of my
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Property &vner Print and Sign
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5p€clãl Cond¡t¡ons:
Pe¡mit Feel
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Perk Fe€:
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Total Fees:(fl.16 ffi&ââs
W;rîå.3å3ry-naÒ Ealañce Due:
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