HomeMy WebLinkAboutApplicationEL - Garfield CoRvlaw
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Community Development Department
OCT 2 4 1014 108 8" Street, Suite 401
GAkE IF LQ COUN"f Glenwood Springs, CO 81601
(970) 94
)MMUNITY DEVE).OFME;aj 5'
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TYPE OF CONSTRUCTION
IR New Installation ❑ Alteration ❑ Repair
-WASTE TYPE
Dwelling ❑ Transient Use ❑ Comm/Industrial ❑ Non -Domestic
Other Describe
INVOLVED PARTIES
Property Owner: C), P.\ 12.,ce l Phone: ("AX) ) 2 71-9 o
Mailing Address: `-62 Na _,a- Aj E r C"J 5A\ , -S
Contractor: Phone: (TSct ) 9Z9 *4°10`1
Mailing Address: '6z-
SZEngineer:
Engineer:
L,v� Phone:( ) 3C -S2�
Mailing Address: 3 ;yTgc e-
PROJECT NAME AND LOCATION
Job Address. T G ,> C -C> 'i5\ 23
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: #Bedrooms: 2- Garbage Grinder -AID
Distance to Nearest Community Sewer System: I071
Was an effort made to connect to the Community Sewer System:* --7 , T '7 A-7- c } qe_t rte'
Type of OWTS
Septic Tank 1
11eration Plant
❑Vault ❑ Vault Privy
❑ Composting Toilet
❑ Recycling, Potable Use
❑ Recycling
❑ Pit Privy
❑ Incineration Toilet
❑ Chemical Toilet 1
❑ Other.
Ground Conditions
Depth to 1s' Ground water table 9`iC Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit
❑Underground Dispersal
❑ Above Ground Dispersal
❑ Evapotranspiration
❑ Wastewater Pond
❑ Sand Filter
❑ Other
Water Source & Type
❑ Well
❑ Spring
❑ Stream or Creek ❑ Cistern
F)3 Community Water System Name.5AT(Ay.W,E,i. t. r4Tso ^
Effluent
WIII Effluent be discharged directly into waters of the State? 0 Yes IR No
CERTIFICATION
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 re and understand the Notice and Certification above as well as
have provided the required informa io w t and accurate to the best of my knowledge.
C--�A (+—� S 1 va 6t.1 Z
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions: /moi
ErryirLrPrs �sts�i�//�i�ll� /*/MW,00/ / '�'l//✓% /�`Yue.Yv/ ��A/ G. o.
Permit Fee:
123.60
Perk Fee:
a
Total Fees:
113 • "
Fees Paid:
17 3 . �o
Bulling Perini
Septic Permit:
Issue Date:
Balance Due:
BLDG DIV:
APPROVAL
DAT
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