HomeMy WebLinkAboutApplication - VOIDEDja Garfield County
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Community Development Department
108 8t' Street, Suite 401
GAF'F'ELI) COUS)OFM pGlenwood Springs, CO 81601
COMMUNITY DF\11-1- E (970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION _
0: New Installation ❑ Alteration
❑ Repair
WASTE TYPE
Rf Dwelling ❑ Transient Use 113 Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Phone: (_ `'l 0) / `'6` 6 51,
Mailing Address:
Email Address: j't4" /s bf -.h zow2+,. L° 4,VL ,j. Goy
Contractor: M 4c- /q buue Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: ( )
Mailing Address:
Email Address: —
PROJECT NAME AND LOCATION
Job Address: f r e y —5-1 V_ �a / 6-
Assessor's Parcel Number: Lot Lot Block
Building or Service Type: /�7G� #Bedrooms: _� Garbage Disposal(Y/N) /
uistance to ivearest community newer system: d Les AID
Was an effort made to connect to the Community Sewer System: /I D
Type of OWTS
0 Septic Tank
❑ Aeration Plant
❑ Vault
❑ Vault Privy
Composting Toilet
❑ Recycling, Potable Use ❑ Recycling
1 ❑ Pit Privy
❑ Incineration Toilet
❑ Chemical Toilet ❑ Other
Ground Conditions
Depth to 15t Ground water table
Percent Ground Slope
Final Disposal by
❑ Absorption trench, Bed or Pit
❑ Underground Dispersal
❑ Above Ground Dispersal
❑ Evapotranspiration . ❑ Wastewater Pond ❑ Sand Filter
❑ Other
Water Source & Type
® Well
❑ Spring
❑ Stream or Creek
❑ Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 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 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 informatioonl which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
V Z3 • oo
➢Fee—
Total Fees:
I t3• 00
Fees Paid:
123. 00
Building Permit
61�E -bll�-
Septic Permit:
SEA-(0US
Issue Date:
Balance Due:
BUILDING/ PLANNING DIVISION:
Signed Approval Date
?P-1F 123.00j cc, xlmlzoto