HomeMy WebLinkAboutApplication.pdfc:E' Garfield County Cl:mmunity Development Depart ment 108 8tn Sreet. 3Jlte 401 Genwood ~rings. CD 81601 (970) 945-8212 www.garfield-cou nty.oom 1 NOIVl DUAL ffilVAGE 01 s=Dsc\L SYSTBV1
(lffiS) PERM IT APPUCA llON I T'iPEOF(D\JSTRUcnCN ~ New Installatirn I WASTET'iPE o ftJteratirn tt Dwelling 0 Transient Use , 0 Cl:mmllndustrial o Gher Describe '---------'-=---"'-"
~NAMEANDLOCA~ON .bb Mdress: I ?''>r 7..21.. a 'i2.cl o A;pair o Non-Domestic Assessor's Parcel Number: '2-1'2-7{)]" 3 00 I 113Jb. --------Lot Block BJilding cr i:frvice Type: Yg;"cI
.enb;Q #Bedrooms: -,Z=-_Garbage GinderU 0 Dstance to Nearest Cl:mmunity i:fwer cystem-I. I. m.. .. I .I{. ~-Was all effort madeto connect tothe Cbmmunity i:fwer cyst em: IJD Type of
IllS \0.. SapticTank 0 Aeration Aant I 0 Vallt I 0 Vallt A'ivy 0 Olmpostlng Toilet 1 0 Rlcycllng.PotableUse 10 Rlcycllng I 0 At Privy I 0 IndneralonToliet -I I o Chemica Toilet 0 aher
I I Qound Cbnditions Depth to l' Qoundwater table Percent Qound Sope Rnal Dsposal by 0 Absorptlontrend1. Bed or At ~ Underground aspersal 0 Above Qound DIspersal I 0 Btapotransplratlon
' 0 Wast owater Pond I 0 SInd Riter 1I 0 aher ____________-__________ Water 8:x.trce & Type 0 Well I 0 ::j>rlng I 0 Sream or Oeek I!J. astern o Olmmunlly Water Sfstem Name ______________
_ Hfluent Vlllil Effluent be dlsd1arged directly Into wat ers of the Sa.? 0 Yes
aRTlACA.TlON lq5plicant 'aCRnCMIleagestnarfne comPletenessoffne applicafion is'conaitional upon'suGh-furfner mandatory and additional te& and reports asmay 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 evaluat ion I of the application; and the issuance of the permit is subject
to such terms and conditionsas deemed necessary to insure compliance with rules and regJlations made, information and reports submitted herewith and required to be submitted by the applicant
are (X will be represented to be true and correct tothe beg of my knCMIledge and belief and are de!igned 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 undergand that any falsification or mis-epresentatiOl'l may result in the denial of the appl ical ion or revocation of any
permit g'anted based upon said application and legal action for perjury as provided bylaw. I hereby acknowledge that I have read and undergand the Notice and certification above aswell
as have providedtherequired information whidh is correct and accurateto the be& of my knowledge. ~edal Qmdit Ions: Permit Fee: ElJlldlng Fl>rmlt Fl>rk Fee: 100 ~ S!ptlc Permit: ::,,~.-::
Date Tolal Fees: ~iPa'd: ~ DAlE