HomeMy WebLinkAboutApplicationl ECEI\7EU
MAY c. ) 2015
;,.•LN!TY DPIFL PM• ! ar e u ounty ·-;i>.RFtELo coE G fl l',, c
Community Development Department
108 S"' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
JD New Installation I D Alteration
WASTE TYPE
tiil Dwelling I 0 Transient Use !D Comm/Industrial
l IE Other Describe AMP i-1J;t-16 :ii'"a ;>-' .S,'~oj>
I NVOLVED PARTIES
I 0 Repair
-l D Non-Domestic
Property Owner: l'A,_R.-t..0-. -S--D.,........._c.A ___ 1_<""'0-c. ___ 'N_,c\_S ______ Ph_o_n_e_: _( _+_t _+_)_+_o_b"""---'811 f.::J
MailingAddress: ,-'110 '() vt;~<;H1,JGT-t;i'J B&..vi:>
---------,,-----------------------~--------Contractor: __ o ___ u.J_,_.J_C:_R _______________ Phone:( ___ --------
Mailing Address: ______________________________ _
Engineer: ____________________ Phone:( ___ --------
Mailing Address: ______________________________ _
1 PROJECT NAME AND LOCATION
Job Address: Z3-\-5 i-lo m ~ 5"TeA.O ~-op..~·-~Pa-1 ...i C:. \//\u..£Y -l!.u:,.J""''-.:>il Sf,'!11.u-.
Assessor's Parcel Number: "Z.lf\'7Z.i...~Dcoi~ Sub. !~Ome ~!];;Ab G S.IA'ICS lot ;~ Block --
Building or Service Type: ~ o rn E L 1...1"'""6 t:f.4~E -;;11of #Bedrooms:
I
s Garbage Grinder 0
Distance to Nearest Community Sewer System: NL.!:!t
Was an effort made to connect to the Community Sewer System: JJ {4 I
TypeofOWTS ~ Septic Tank D Aeration Plant I a Vault I 0 Vault Privy 1 0 Composting Toilet
D Recycling, Potable Use ' D Recydlng l D Pit Privy j D Incineration Toilet
D Chemical Toi let I D Other
Ground Conditions I Depth to 11 Ground water table '"> 7~ S. · Percent Ground Slope
W£U. llo f~U.L. ·-.. DC. T
aacl'. ..
Final Disposal by D Absorption trench, Bed or Pit I D Underground Dispersal j D Above Ground Dispersal
---D Evapotransplratlon ' D Wastewater Pond 0 Sand Filter
--0 Other
'
Water Source & Type &:I Well I D Spring I D Stream or Creek ' a astern
D Community Water System Name -----Effluent Will Effluent be discharged directly Into waters of the State? 0 Yes af.No
·---·-
GERnfilG'ATIQN
Applicant acknowledges that the completeness of the application is conditional upon such urther
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.
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 .
C/"1~L()_$ D <:A,2.DENA< &~ = M~t z,:z., ;t,o/S
Property Owner Print and Sign z>-Date
0Ff.l~USJ ON~Y
Spedal Conditions :
Permit Fee: Perk Fee: Total Fees: 1u.oo 1~-oo 1-1-E>. 00
Issue Date:
6 "~-ZIJJ5
DATE