HomeMy WebLinkAboutApplication.pdfRECEi¥G Garfield County Community Development Department FEB 0 5 1014 108 8th Street, Suite 401 INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) GARFIELD COUNTY Glenwood Springs, CO 81601 'l,'MUNITY
OElfFI.OPMEW (970) 945-8212 www.garfield-county.com PERMIT APPLICATION TYPE OF CONSTRUCTION 0 New Installation 10 Alteration 1 -Repair WASTE TYPE 0 Dwelling 1 0 Transient Use I -Comm/lndustrial
10 Non-Domestic o Other Describe office s~ace INVOLVED PARTIES Property Owner: RTF 114 RD LLClTeresa and Ronald Fuller Phone: ( 970 )945-5524 Mailing Address: 1067 Park West Dr., Glenwood
SQrings, CO 81601 Contractor: Stel?:hen Burns Phone: ( 970 ) 379-7815 Mailing Address: P.O. Box 418, Sill, CO 81652 Engineer: Richard Petz Phone: ( 970 ) 309-5259 Mailing Address: 33
Four Wheel Orive Rd, Carbondale, CO 81623 PROJECT NAME AND LOCATION Job Address: nnQ7 r.nuntv Road 114. CO 81601 Assessor's Parcel Number: 239501100156 Sub. Fuller Ex. Tract A Lot Block
--Building or Service Type: Warehouse w/office sl1ace #Bedrooms: Garbage Grinder_ Distance to Nearest Community Sewer System: unknown Was an effort made to connect to the Community Sewer
System: no Type oflSDS • Septic Tank I 0 Aeration Plant I 0 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 o Other Ground Conditions Depth to I n Ground water table grealerthan 12 feel I Percent Ground Slope 0-5% Final Disposal by o Absorption trench, Bed or Pit I 0 Underground Dispersal
I 0 Above Ground Dispersal o Evapotranspiration o Wastewater Pond I 0 Sand Filter • Other Ort Well Water Source & Type • Well ! D Spring ! 0 Stream or Creek I 0 Cistern o 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 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 information which is correct and accurate to the best of my knowledge. '--R.,r-JI'-I 7<~t!-" 1vwa~~ ,1l2a//1<4jflh/4 4 /;'1 Property Owner Print
and Sign Date 7 OFFICIAL USE ONLY Special Conditions: Permit Fee: 13 Perk Fee: Total Fees: Fees paidbo .....-1-' ~73 BUil~ TAit Septic Permit: IssueDa~ 8al~ue: (\ N-10t-2oI0S ().S BLOGDIV:
~ \cO 2,S-ZD¥ APp;ibvU ' DATE . t-a:iI:i ~ ~