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HomeMy WebLinkAboutApplicationGarfield County JUN Tcpngity Development Department 1 :lc Street, Suite 401 � 0' • • • � Springs, CO 81601 970) 9145-8212 www.garfieId-countv.com GARFIELD COMMUNITY INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PERMIT APPLICATION TYPE OF CONSTRUCTION • New Installation • Alteration • Repair WASTE TYPE ■ Dwelling f • Transient Use • Comm/Industrial • Non -Domestic • Other Describe INVOLVED PARTIES Property Owner: Donna Dale Mailing Address: 5355 County Road 100. Carbondale, CO 81623 Contractor: F I �sY►ar► �-�� Mailing Address: / 47 G ce_cirr..=;.� Phone: ( 970 )7Q4-9881 Phone: ('ZW ) Cii-0001,12 CD Fa & ?-3 Engineer: Phone: ( Mailing Address: PROJECT NAME AND LOCATION Job Address: 5355 County Road 100, Carbondale. CO 81623 Assessor's Parcel Number: 239324400146 Building or Service Type: Replace Septic Sub. Distance to Nearest Community Sewer System: Rural Lot Block #Bedrooms: • Garbage Grinder 4- wt -bus Was an effort made to connect to the Community Sewer System: A 1v Type of ISDS • Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet O Recycling, Potable Use —❑ Chemical Toilet Ground Conditions O Recycling ❑ Pit Privy 0 Incineration Toilet 0 Other. Depth to 15£Ground water table Percent Ground Slope Final Disposal by • Absorption trench, Bed or Pit 0 Underground Dispersal t Evapotranspiration O Wastewater Pond 0 Above Ground Dispersal 0 Sand Filter O Other Water Source & Type Effluent • Well © Spring I 0 Stream or Creek 0 Cistern O Community Water System Name - - Will Effluent be discharged directly into waters of the State? 12 11gs'(o ac, LL. ❑ Yes ■ No CERTIFICATION Applicant acknowledges that the completeness of the appiiLa lion is col arliLiuudI 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 provided the required information which is correct and accurate to the best of my knowledge. ILY ed, Donna Dale Property Owner Print and Sign 09/10/2018 Date OFFICIAL USE ONLY Special Conditions: 6 I it_ -i �j'ito « X -i - l —�j`J Permit Fee: Perk Fee: Total Fees: Fees Paid: Building Permit Septic Permit: Issue Date: 1 Balance Due: BLDG DIV: ..r `� --)2---2-0 / APPRO L DATE 11D=4 iS- t0) C C, '