HomeMy WebLinkAboutApplication.pdfRECEIVED SEP 26~ GARFIELD (OU Garfield County )MMUNITY DE I ... Community Development Department 108 8" Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com
INDIVIDUAL SEWAGE DISPOSAL SYSTEM (1505) PERMIT APPLICATION TYPE OF CONSTRUCTION ----------------------------------------o New Inst allation I 0 Alteration I • Repair WASTE TYPE f-:;.;
• r --• Dwellin g~_ 0 Transient Use o Other Describe -=--=--=-L D-C-omm-/I-n-du-s-tria~I~~~-,-cD=-N-o-n---Do-m--:-.e::s~t~ic===--_-j INVOLVED PARTIES Property Owner: Lawrence Anthony
DiGuglielmo II Phone: (~)876-~~no MallingAddress: 963 Coun!v Road 229 Silt, CO 81652 Contractor: //? V'~ -.e:. :.?"S<'('~ Phone: (~) ;;I:,,, -c:J/¥~-Mailing Address: Engineer: ,;1//,4
Phone: (_ _) 7 Mailing Address: PROJECT NAME AND LOCATION Job Address: 963 Roar! 229 Sill CO 81652 Assessor's Parcel Number: 2179-051-00-642 Sub. lot ---Block --Building or Service Type:
Residential Home #Bedrooms: 3 Garbage Grinder : Y Distance to Nearest Community Sewer System: 1.5 Miles Was an effort made to connect to the Community Sewer System: No Type oflSDS •
Septic Tank I [] Aeration Plant I [] Vault I [] Vault Privy T [] Compostlng Toilet [] Recycling, Potable Use [] Recycling ! [J Pit Privy I [J Incineration Toilet [] Chemical Toilet [J
Other Ground Conditions Depth to 1st Ground water table I Percent Ground Slope Final Disposal by ~Absorptlon trench, Sed or Pit I Cl Underground Dispersal I [] Above Ground Dispersal
D Evapotranspiration D Wastewater Pond I [] Sand Filter ---[J Other Water Source & Type ! we~ .. [] Spring I [] Stream or cre~l D Cls~ern --D Community Water System Name Effluent Will
Effluent be discharged directly Into waters of the State? DYes ~No -
CERTIFICATION Applicant acknowledges that the completeness of the application is condffiona-I 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 rmatlon which Is correct and accurate to the best of my knowledge. Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: "7 J gO Perk Fee: ~
Total Fees: Fees Paid: 10 0 .nil '1-3--$t."~ . -Building Permit ~p~:m~~qq ISQe. ~~. \3 Balance Due: --BLDG DIV: '&.~ '~'e"& ;~ • l,. ~~)7 APPROVAL DATE 7 "5P q.o, . \::J