HomeMy WebLinkAboutApplication.pdfcE' Garfield County . , . ':\ f\.Community Development Department Rl? CIl IV EjU 108 8th Stre~t, Suite 401 :.I:J Glenwood Sprongs, CO 81601 INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISD5) (970)
945-8212 OCT 1 5 2U13 www.garfield-county.com GARFIELD COUNTY iMMUNITY DEV E,-'tYl'IE'OF CONSTRUCTION i!I New Insta llat ion WASTE TYPE PERMIT APPLICATION 10 Alteration 1 0 Repair i!I
Dwelling 10 Tra nsient Use 10 Comm/lndustria l 1 Non-Domestic o Other Describe INVOLVED PARTIES Property Owner: James W Langstaff, Trust & Lesler Earl Trust & Setsuko Trust Phone:(~)
625-2246 Mailing Address: 1397 Munro Avenue, Rifle, CO 81650 Contractor: WPX Energy Rocky Mountain, llC Phone: (~) 285·.377 en 220. Mailing Address: PO Box 370, Parachute, C0 81635 Engineer:
David Fox Phone: (~) 250·5505 Mailing Address: PO Box 370, Parachute, C081635 PROJECT NAME AND LOCATION Job Address: RMV 12-16 -Please see plals for desciplion Assessor's Parcel Number:
217516300017 Sub. Lot ---Block ---Building or Service Type: Temporary office & house #Bedrooms: 2 Garbage Grinder No Distance to Nearest Community Sewer System: NA Was an effort made
to connect to the Community Sewer System: NA Type oflSDS o Septic Tank I 0 Aeration Plant I iii Vault I 0 Vault Privy I 0 Composting Toilet o Recycling, Potable Use o Recycling I 0 Pit
Privy I 0 Incineration Toilet o Chemical Toilet Ii Other Hal.lledloOownValleyWasteforltleio'disposai Ground Conditions Depth to 11 Ground water table NA I Percent Ground Slope NA Final
Disposal by 0 Absorption trench, Bed or Pit I 0 Underground Dispersal I 0 Above Ground Dispersal 0 Evapotranspiration o Wastewater Pond I 0 Sand Filter Ii Other Hauled loDown Valley
Wasle for !heM" disposal Water Source & Type 0 Well I 0 Spring I 0 Stream or Creek I 0 Ci stern Ii Community Water System Name Down Val ley Septic and Waste Effluent Will Effluent be
discharged directly into waters of the State? DYes Ii 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 wi ll 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 hea lth in evaluating
the same for purposes of issu ing the permit applied for herein. I further understand that any falsification or misreprese ntation 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 reoa d an§~nl erstand the Notice and Certification
above as well as have provided the required information "kich i correct and accurate to the best of my knowledge. ?,;?~ . ~ -----.. i O//'1113 Date j I OFFICIAL USE ONl V Special Conditions:
pe~7J,~~ :$ . Pi,k;;~ Total FeeCLQ... ~~ ::F/Jle ~~i'~bo Building Permit \ SePti~ i~~'2" Issue Date: . \~ BalanceJr!L., (). \:") -'I> O· BLDG DIV; --.j \\ "-Q'Ii:z 2!i::\LS. APPROVA~
~ DATE y'O..~ '()~~' ~t ::i73.£Q ~ :;!