HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8t" Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
TYPE OF CONSTRUCTION
IL K3. New Installation
WASTE TYPE
... Dwelling , 0 Transient Use 0 Comm/Industrial 0 Non -Domestic
0 Other Describe
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
0 Alteration
0 Repair
INVOLVED PARTIES
Property Owner: Edna Elaine Place
Mailing Address: 2010 Rd 250 Silt, CO 81652
Phone: (. 970
Work 970-384-3700 Ext 1804 Garco County C & R
Contractor: Phone: (
Mailing Address:
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:At) }0 i &
Assessor's Parcel Number: 2125-311-00-044 Sub.
`R 5 —
Lot Block
Building or Service Type: [f CC m 1, Jar- #Bedrooms: � Garbage Grinder
Distance to Nearest Community Sewer System: 3 t 6 -es
Was an effort made to connect to the Community Sewer System:
Type of ISDS
91 Septic Tank 0 Aeration Plant D Vault 0 Vault Privy
0 Composting Toilet
O Recycling, Potable Use 0 Recyding 0 Pit Privy 0 Indneration Toilet
0 Chemical Toilet
0 Other
Ground Conditions
Depth to 1s` Ground water table
Percent Ground Slope
Final Disposal by
0 Absorption trench, Bed or Pit
O Evapotranspiration
O Other
0 Underground Dispersal I 0 Above Ground Dispersal
0 Wastewater Pond I
0 Sand Filter
Water Source & Type 0 Well 0 Spring 0 Stream or Creek
Effluent
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes 0 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. 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.
1 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.
Edna E Place
Property Owner Print and Sign
2.00ro0,
Date
OFFICIAL. USE ONLY
Special Conditions:
Permit Fee:
, 2 3. eVi
Perk Fee:
Sc'. o a
Total F es:
233.00
Fees Paid:
2-3.00
Building131,M- Permit- •
Septicr�Permit: 3 1
Issueit I IV
Balance Dude:
ll
BLDG DIV: ', , 7 .'2•Q/6
• PRO L DATE
•
�1.*21-315D) VISk,ilIS