HomeMy WebLinkAboutApplicationGarfield County
ommunity Development Department
REGEiV� 108 8th Street, Suite 401
lilf.s Glenwood Springs, CO 81601
�h �4i 11 4 CDUtiTI (970) 945-8212
ARFIEYD I.ugt4�rVluw.earfieId-county corn
(icommTYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
la Dwelling ; ❑ Transient Use 0 Comm/Industrial
0 Other Describe
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
❑ Alteration
Ai Repair
Non -Domestic
INVOLVED PARTIES
Property Owner: 14v te,13..s»A Phone:( i7O ) 371
Mailing Address: S lo 1 C F � �,' / Cd «graz2
Contractor: 'f (Sc {'reti+nrn% r ,(&) Phone: ( C1 - ) 2) )1 - G 8
Mailing Address:
Engineer: oh Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
yob Address: S io ((-2 3 P jn , [ v P6 -
W
Assessor's Parcel Number: o? 177satr, 03 S-3 Sub. ,.r -c• cvv-, Lot Block
Building or Service Type: h -t,, #Bedrooms: y Garbage Grinder 1
Distance to Nearest Community Sewer System: 417 VVI i1 ti
Was an effort made to connect to the Community Sewer System: isf /Ar
Type of ISDS
Septic Tank ❑ Aeration Plant D Vault 13 Vault Privy D Composting Toilet
O Recycling, Potable Use 1 0 Recyding 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to 151 Ground water table Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit VI Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Send Filter
O Other
Water Source & Type Els Well 0 Spring 0 Stream or Creek 0 Cistern
O Community Water System Name
WIlI Effluent be discharged directly Into waters of the State?
Effluent
0 Yes R.No
1
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 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 he 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.
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.
1 hereby acknowledge that 1 have read and understand the Notice and Certification above as well as
have provided the required information which is cgrrect and accurate to the best of my knowledge.
Property Owner Print and Sign
3 /47)
Date
OFFICIAL USE ONLY
Special Condltions:
Permit Fee: 113.OD
Perk Fee
Total Fees: ��
Fees Paid: 1.3. 60
Building Permit
Set Permit:_
sed'- 41 b2
Issue Da
3 0 3OW _
Balance Due:
........
BLDG DIV: f 7 - 6 -))//e7/6 -yo
APPROVAL DATE
ID.123 .00) r 1941 32O2O