HomeMy WebLinkAboutApplicationl'\1C¥JV~ Garfield County JUNlOlU~
UN 1 Community Development Department
G/\RflELD C~ O"' ~ 108 8th Street, Suite 401 ~l .\~~u ·~n'< DL \JcL rill-Glenwood Springs, co 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
~ New Installation
ASTE TYPE
I D Alter_at_io_n _____ ~_a __ R-'ep"-a_ir_
p( Dwel-li-ng--~,-D_T_r_a-ns-ie_n_t_U_s_e-~-=-~~IJ-0--C-o_m_m ___ /l-n-du_s_t-ria-l--~-D-Non-Dom_es_t _ic __ ---i
0 Other Describe
L ----------------------------
INVOLVED PARTIES
Property Owner: ..... fl .... --G\~c_.Z_ ...... ......__ ..... ;V"-._i\.......;......:.;-.....::w./J ________ Phone: ('I '" ) JJ"I -<-! 7 2 z
MailingAddress:J.el.. f . 8111 C~IC fJ.o , .. / C.:.rf,,,,J, I~ Co ~I (J-l
Contractor:-k?...._r...,.l _<' __ --P._..l w._..<:..___ ____________ Phone:(._ _ _, _______ _
Mailing Address: ____________________________ _
Engineer: ~7/.,, c:iff 6 &~1:t r -Phone: ( 'fJd} 7 d '( , 0 '( l'I
MailingAddress: f ? fg .,r ~(( {tJ Cc c:lc.,/s u. co ti 6&
I PROJECT NAME AND LOCATION
Job Address: 4 'to l C Si t '<-6' t~, i-0 11 1-[frt ..... r CU ?/{ IJI
SJ '1f£ -()/X: '0 7-"" 3 7 •
Assessor's Parcel Number: K. l/t 46 '( Sub.--------Lot __ Block
Building or Service Type: #Bedrooms: ____ Garbage Grinder_
Distance to Nearest Community Sewer System:_?'""-. _l_""_1_fl ______________ _
Was an effort made to connect to the Community Sewer System: .... # ........ o_· --------~-
Type of OWTS Jl:"Septlc Tank I c Aeration Plant I c Vault I c Vault Privy I c Composting Toilet
c Rec;ydlng. Potable Use a Recydlns I a Pit Privy I c Incineration Toilet
------· 0 ChemlcalTollet C Other ______________ _
Ground Conditions j Depth to 111 Ground water table j Percent Ground Slope ------
Final Disposal by a Absorption trench, Bed or Pit I a Underground Dispersal ! a Above Ground Dispersal
c Evapotransplratlon ~ Wastewater Pond I a Sand Fiiter
a Other ______________________ _
Water Source & Type J!l Well I a Spring I a Stream or Creek a Cistern
0 Community Water System Name _______________ _
Effluent Wiii Effluent be discharged directly Into waters of the State? 0 Yes -Ji[No
CERTIFICATION
Applicant ack.-n-o-w--,-le_d_·_g_e_s __,th_a_t the completeness of t he 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.
G-ttJ-(f
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Total Fees: Fees Paid:
I . OD I . OD i..;. 00
Building Permit Septic Permit: Issue Date:
T,3~=to +. \·\~
~-ID-/5
DATE