HomeMy WebLinkAboutApplicationCommunity Development Department
108 sth Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
D New Installation Alteration
WASTE TYPE
D Dwelling Cl Transient Use omm ./Industrial
D Other Describe ---------------------------------
INVOLVED PARTIES
Property Owner: .....6..L..L....LiO;.__..i......t;.¥.J:JJJ..u:;..L.J...~~~~:::.........!:o...A...io--Phone: (~712 l...-........ .___..&....:.'--......... "--'
Mailing Address: 6-o;·tzL&T. C!.c; )<I ~o 7A
Contractor: Phone: ( ) -----------,----1
MailingAddress: ?ovr.J ..f.ry,L/.-/ 240 7 Gkad&r/.$rTJ 8/t. /
Engineer: ___________________ Phone:( __ _, _______ __
Mailing Address=------------------------------
PROJECT NAME ANO LOCATION
Assessor's Parcel Number: Sub. lot Block -------------
8 u i Id in g or Service Type:/czn41<f;-(t~ fl #Bedrooms: Garbage Grinder_ . ------
0 is tan c e to Nearest Community Sewer System : --~....,_ ....... 1___,,kz _ _.v'--------------
Was an effort made to connect to the Community Sewer System:-------------
TypeofOWTS Jilseptic Tank CJ Aeration Plant CJ Vault CJ Vault Privy CJ Composting Toilet
CJ Recyding, Potable Use D Recycllng 0 Pit Privy D Incineration Toilet
D Chemical Toilet D Other _______________ _
Ground Conditions Depth to 1 Ground water table-----Percent Ground Slope ------
Final Disposal by Absorption trench, Bed or Pit Underground Dispersal [J Above Ground Dispersal
CJ Evapotransplration D Wastewater Pond D Sand Filter
D Other _______________________ _
Water Source & Type 'fi'I... Well CJ Spring CJ Stream or Creek 0 Cistem
D Community Water System Name ________________ _
Effluent Will Effluent be discharged directly Into waters of the State? CJ Yes CJ No
€ERiJ11FIGATIGN.
Applicant ackn-o-w"""l~ed""'g .. e_s_t ... h -at-t"'"h_e_c_o _m_p_l""e-t-en_e_s_s_o..,..f .,..,...the appJication is condi tional 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 regulati ons 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 informati on which is correct and accurate to the best of my knowledge.
!fJ.F{le t::.,::i"4~-£R LJ/1Lpork.J~ff7/a <:>L; .S--. }
Property Owner Print and Sign Date
OFFIC::lAI: USI 0NLY
Fees Pai~
Balance Due : $ 00
7--2~-2.0/5
DATE