HomeMy WebLinkAboutApplicationce; Garfield CountjJ
Community Development Department
~ 108 3th Street, Suite 401 _E c E IV re~wood Springs, co 81601
J ' (970) 945-8212
JUN 1 3 ZDJ6 www.garfield-county.com
WASTE TYPE
_______ lii_Repair _ ~=-J
1-=-il Dwelling 0 Transient Use C Comm./lndustrial C Non-Domestic
r
0 Other Describe
~------------------------------~
INVOLVED PARTIES
Property Owner: Thomas E Jr & Shauna M Swale
Mailing Address: 0013 aueen City Circle Parachute. co 81635
Contractor: B&B Plumbing & Heating
Mailing Address: 1831 Railroad Ave. Rme . co 81650
Engineer: Jefferey S Simonson
Mailing Address: 118 w Sixth Street, Suite 200 Glenwood Springs, co 81601
PROJECT NAME AND LOCATION
Job Address: 411 237 County Raad, s111. co 81652
Phone:( ___ --------
Phone: (_9_1o __ )_s_2s._J_31_0 _____ _
Phone: (_91_0 __ }_94_s._1_0_04 _____ _
Assessor's Parcel Number: 212735401004 Sub. _________ Lot ___ Block
Building or Service Type: _R_es_id_e_nce _________ #Bedrooms: _2 ____ Garbage Grinder __
Distance to Nearest Community Sewer System: _5_.0_00_11 ___________________ _
Was an effort made to connect to the Community Sewer System: _N_o ____________ _
TypeofOWTS Ii Septic Tank C Aeration Plant I a Vault C Vault Privy a Composting Toilet
C Recycling, Potable Use C Recycling r C Pit Privy ---
I C Incineration Toilet
C Chemical Toilet C Other
Ground Conditions Depth to 1" Ground water table Greater"''" an Percent Ground Slope 2"'
'
Final Disposal by Iii Absorption trench, Bed or Pit C Underground Dispersal C Above Ground Dispersal
--C Evapotr;.:;-spiratlon r C Wastewater Pond C Sand Filter
C Other --Water Source & Type Iii Well l C Spring -re-Stream or Creek C Cistern
C Community Water System Name __________________ _
Effluent Will Effluent be discharged directly into waters of the State? C Yes Iii No
'CERTIFICATION
Applicant acknowledges that the completeness offhe appllC ation is cond itionafupon 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 . l
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.
]
OFFICIAL
Special Conditions:
e that I have read and understand the Notice and Certification above as well as
quired information which is correct and accurate to the best of my knowledge.
Dat~/¥/v
Perk Fee: T~IFees: OO 76
00
lo-/2).0~ ,
DATE