HomeMy WebLinkAboutApplication.pdfCommunity Development Department
108 8m Street, Suite 401
Glenwood Springs, CO 81601
(970)945-8212
www.garfield-county.com
11DIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATIpi�l.
E'( CONSTRI3CTION
ew Installation I Cl Alteration J D--itepair 1
L�J{STE EYPE ,
U' PWelling 1 0 Transient Use 0 Comm/Industrial Lo Non -Domestic
0 Other Describe
INvO.IEp PARTIfg^s�p� �'/
Property Owner: �/lYonr a a /i28tie Phone: (
Mailing Address: r000a,No nAkr y,,/o✓ru//7'w✓Zi'%sU/o
Contractors Cfea7c%pp
cf Krs,s.rt,4xt,cXr
4 Phone: (977j 37V 0 / 6/
Mailing. Address: /0 /> 9 3 /3 ,4L,64,„6.-0
/( 07
Engineer: j c+cvcy Wad) frroAz z ulirk/ee✓ Ap Phone: C 77 ) 70F 0 r//
Mailing Address: 1
pflt»E T:lNAMEAN6LOCAT')IOld <'
Job Address. 82 6 E/t rt coni reoos,, 44 .ZQnt/- , Ski E 07
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
2/2S25/0490/2 Sub,1, ji t v.r,, a, Lot /3 Block,.___
cs/GrA//i4/ #Bedrooms: 5-- GarbageGrindev!
,
Sewer System:
connect to the Community
SGC"
Sewer System: /P//,9
Type Df iSDS "
0-8e ptic•pnk EL:Aeration Plant J q Vault I 0 Vault Privy. l 0 Composting Toilet
D Recycling Potable Die
Q. Recycling r O Pit Privy - 1 Q Incineration Toilet
Q Chemical Toilet':.
0 Other
Slope/ 5"-
Ground Conditions
Depth to l" Ground water table
�"24O I�Ground
Pfoal Dfgposal.b`y.
0 Ahsorptiontregcfi,pert orPit . ❑ Underground Dispersal 13 AboveGroundDispersal.
Q Evapotranspiration 1 Q Wostewater Pond Er Sand Filter
0 Other - ,
, S'o.vrF J S ... e ' . /or, r dcraarrv't
Water Source & Type
❑ Well 1 O Spring T ❑ Stream or Creek 0 Cistern
Q Community Water System
Name/^//f fust! -6" /G.
Effluent
Will Effluent bedischargeddirectly Into wateriofthe State? 0 Yes G'No
!Yri:-Ci'11t� }JIYY S.. ,'•E -4
J -1 JA4 �:.,,.1 /
Applicant acl<nowle3ges that the completeness of the application is conditioriafupon 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, 1
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,
( 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.
Prr laerty Owner Print and Sign GA-921A—cVer V eci&j:t&.
Date
C7FF1CiA! lJSE{?1A41,Y
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.SpecialConditions:
Permit Fee: Perk Fee: Q oo
1. DD
Total Fees:
b�
Fees Paid:
iS�• CO
Building Per i Septic Permit:
` a: 32
13LDG DIV: OW.�
A•PP'VAL
\
Issuete:�
-1
Balance Due:
D•OD
.s.Y 3 20
I
DATE
F 49-s .00