HomeMy WebLinkAboutApplicationRE C. Garfield County JUN ~ Community Development Department
GARFIELD COUNTY 108 8th Street, Suite 401
)MMUN1TY DEVE 1 O'"\Glenwood Springs, co 81601
(970} 945-8212
www.garfield-county.com
TYPj OF CONSTRUCTION
, I I
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
Cir' New Installation D Alteration D Repair
WASTE TYPE ~welling D Transient Use D Comm/Industrial D Non-Domestic
D Other Describe -----------------------------
INVOLVED PARTIES , •
Property Owner: £d1Parof k 1-e. /;11fl/11 Z. Phone: (q lb ) q_'fi-J:J ?:[+
Mailing Address: --P.=--0 ___ ._JS __ o.....,.)t....,, __ $_~---tq ___________ _
Contractor: 'f.a.bb." Ho/ MP£ Phone:aJIOI 7//?, · 2 oo=J-
Mailing Address: __ 1 ____ f'l__,/t=..._,,_i l ...... 2_5 ............ 1 ...... -_....,,,C---A ..... C.-!AJ ___ µ __ efA............,U.g ___ ....... ((: __ 2 __ _
Engineer: ____________________ Phone:( ___ --------
Mailing Address: _____________________________ _
PROJECT NAME AND LOCATION
Job Address: _______________________________ _
Assessor's Parcel Number:;2 3q JO 5~3aub. ________ Lot Block
Building or Service Type: Dr11 e Iii JI.JS #Bedrooms: (,)_. Garbage Grinder L
Distance to Nearest Community Sewer System: __ __.tfn...-. .... (,,._/....;;e_=--------------
Was an effort made to connect to the Community Sewer System: ... d~J/,..../1..,__ _________ _
;
Type of ISDS llVSepticTank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
0 Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
0 Chemical Toilet 0 Other _______________ _
Ground Conditions Depth to 1st Ground water table ____ _ Percent Ground Slope ------
~
Final Disposal by l!J'" Absorption trench, Bed or Pit D Underground Dispersal 0 Above Ground Dispersal
0 Evapotranspiration 0 Wastewater Pond 0 Sand Filter
0 Other _______________________ _
Water Source & Type CYWen 0 Spring 0 Stream or Creek 0 Cistern
D Community Water System Name-----------------
Effluent 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. 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.
Pro~~f;P.~ Date
OFFICIAL USE ONLY
Special Conditions:
Fees Paid:
'2-f~ DO
Permit Fee:
?.3. DO
Total F~s 7
1-f.:J ·00
Issue Date: Balance Due:
BLDG DIV: d.~'~ APPROV~ ?