HomeMy WebLinkAboutApplicationA il
'' Garfield County
MAY 17 2916
Community Development Department
108 8u' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-coun!j..com
TYPE OF CONSTRUCTION
fcf New Installation C Alteration ❑ Repair
WASTE TYPE
7 Dwelling ' Transient Use ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe!_ _ --
INVOLVED PARTIES
Property Owner: Phone: Q240
I Mailing Address:
Contractor:
Mailing Address:
Engineer.
Mailing Addc ess•
L---- —
PROiE(T NAME AND LOCATION
+ . -)b Anidress:
Phone: ( )
Phone: ()
Assessor's Parcel Number: 053Maub-5,),s IiIEADAW5 GSTa,e Slot Z` Block:
Building or St rvicry Type: Ruin tgr L- #Bedrooms: _ Garbage Grinder
Distance to Nearest Commirr:':ty Sewer System:
Was an effort made to c-,nnect to the Community Sewer System:
Type of OWTS 1d Septic Tank ! 0 Aeration Plant ❑ Vault 1 ❑ Vault Privy ❑ ng Toilet
0 Recycling, Potable Use❑ Recycling 13 C3
Privy 0 Incineration Toilet
0 Chemical Toilet ❑ Other
Ground Conditions Depth to 1` Ground water table I Percent Ground Slope
Final Disposal by 0 Absorption trench; aed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
1-13 vapotranspiratioit Q Wastewater Pond I 0 Sand Filter
I '
C outer
*Nater Source & Type 0 Well 0 Spring ❑ Stream or Creek 11 Cistern
E Community Water System Name _._.
Effluent — 111:;; tr"fiuent be discharged directly into waters of the State? 13 Yes 13 No
CERTIFICATION
L 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.
hereby acknowledge that I have read anti 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.
-�
Property Owner Prin ign Date
OFFICIAL USE ONLY
Special Conditions:
Perit Fee: a O Perk Fee: QO Total Fees: 0c) Fees Paid: OQ
Building Permit Septic Permit: Issue Date: Balance ue
sa-
i BLDG DIV:
APPRO'JAL. DATE
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