HomeMy WebLinkAboutApplication.pdf£11 3U1. Gpg1aD aitailitpimity Development Department 1b8 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com (r-3) INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PERMIT APPLICATION TYPE OF CONSTRUCTION Property Owner: -Ali ` LI tic n Ip C€ Phone: ( Mailing Address: QO 6DY &B Ccc' xo(W 1' CO S« Z'3 I Contractor: 1Q.1YIUr) j\oQ_CLC1G Phone: ( P' New Installation • Alteration • Repair WASTE TYPE )1u7_ Assessor's Parcel Number: 23953 �3D(x) Sub.S r. 35j Lot Block Building or Service Type: Z idem - J #Bedrooms: % Garbage Grinder//2(7 Distance to Nearest Community Sewer System: / Milk — Was an effort made to connect to the Community Sewer System: /10 I, Dwelling • Transient Use 0 Aeration Plant • Comm/Industrial 0 Vault Privy • Non -Domestic • Other Describe 0 Recycling 0 Pit Privy 0 Incineration Toilet ❑ Chemical Toilet 0 Other Ground Conditions Depth to 1s` Ground water table 7-44 Percent Ground Slope //V INVOLVED PARTIES Property Owner: -Ali ` LI tic n Ip C€ Phone: ( Mailing Address: QO 6DY &B Ccc' xo(W 1' CO S« Z'3 I Contractor: 1Q.1YIUr) j\oQ_CLC1G Phone: ( Mailing Address: Engineer: repo c elk 1.eQLi+R5 LLC- Phone: ('311 ) 'c4 -- o2 It i Mailing Address: (j ,,�� PROJECT NAME AND LOCATION Job Address: 0210b V_ -t% Line_ C( I? b0nctai,P, (Uc % )1u7_ Assessor's Parcel Number: 23953 �3D(x) Sub.S r. 35j Lot Block Building or Service Type: Z idem - J #Bedrooms: % Garbage Grinder//2(7 Distance to Nearest Community Sewer System: / Milk — Was an effort made to connect to the Community Sewer System: /10 Type of ISDS jzt. Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet 0 Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet ❑ Chemical Toilet 0 Other Ground Conditions Depth to 1s` Ground water table 7-44 Percent Ground Slope //V Final Disposal by )1 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter/ ❑ Other �'/ /x--14 ,.. /71"'"P7 UJ� TSG1-►' 1-- Water Source & Type Well 0 Spring 0 Stream or Creek 0 Cistern ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 0 No vvere cacte,t(14 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. Propty Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: Perk FCe: eXtcyl Yl,e-e4c-CA Total Fees: y I 2_..;. DO Fees Paid: (13-W Building Permit Septic Permit: Issue Date: Balance Duel/ BLDG DIV: , PP • a+ - DATE pd. 11/ .LOJJ ZL2, -ZS-1,4