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HomeMy WebLinkAboutApplication.pdfOCT 25201. GARFIEL.D COLi;T :MMUNITY DEVEI-UPMC,im� nity Development ()apartment 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945 -8212 wuk_sti, rf(Vid- county!r im Garfwld Countty, TYPE OF CONSTRUCTION (;,i New Installation WASTE TYPE Dwelling f1 Transient Use © Other Describe tAct..'rre=tp £lOrr INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PERMIT APPLICATION G Alteration NI` Repair 0 Comm /Industrial Q Non•Domestic INVOLVED PARTJ[f Property Owner: ..]L 'lit �._.("� % -. Phone: Erp !i,'S i ; I {.rT. - — MaIIInR l"1c �]!a t,0 /, hew e r.� c 'l n Phone: (g _9,3t� —✓1 /.Z, Contractor: Mailing Address: Engineer: Mailing Address: PROJECT NAME Apl D L CATAON Job Address: ] Assessor's Parcel Number: (11-'367) 1 c1 ub. Phone; ici toroecl Lot 5 Block r Service Type: #Bedrooms: - Garbage Grinder 1 Distance to Nearest Community Sewer System; __/Z br r I�5.._ Was an effort made to connect to the Community Sewer System: — ._,„ Type of lSD5 XSePtIc Tank 17 Aeration slant C1 Vault n Vault Privy 0 Composting Toilet EJ Recycling, Potable Use 0 Recycling Li Pit Privy 0 Incineration Toilet Chemical Tow Other Ground Conditions Depth to In Ground water table Percent Ground Slope _— _i Final Disposal by eiSlAbsorptlon trench, Bed or Pit 0 Underground Dispersal Ca Above Ground Dispersal CI Evapotranspiration 0 Wastewater Pond 0 Surd Filter ti tinier . _. .�. ... Water Source & Type Well LI Spring 0 Stream or Creek 0 Cistern 0 Community Water System Name Effluent Will Effluent be discharged directly into waters of the State 0 Yes I 'Sf) I atAD ,Akett:C..j XVd 90 :T'T CT0Z.SZ/OT T00 Ti 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 reguiatlons 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. 1 further understand that any falsification or misrepresentation may result In the dental 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 I have read and understand the Notice and certification above as well as have provided the re ed lnformat • which is correct and accurate to the hest of my knowledge. Viinee fiegor: /3 Property Owner Pflnt and •. Data OFF( IAL USE ONL tFY G Special conditions: Permit Fees Park Foes /0C"-) '`4 pulidin; Permit S00 ill Tot Issue Date Balance flue: e• zs, DAVE 0 TVA 60: TT I;TOV SZ- OT