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HomeMy WebLinkAboutApplicationmy ffiCommunity Development Department 108 8`' Street, Suite 401 Glenwood Springs, CO 81601 �1�U elfG'`+w�earfie d-countv.com G970) 94S-8212 � D TYPE (IF `CONSTAU01-0- - New Installation ❑ Alteration p Repair IM Dwelling p Transient UseB Comm./Industrial Non -Domestic i ©Other Describe INVOLVED'PAR' Property Owner: Mailing Address: I-) VT UL Z'15 Phone;f Contractor: Phone:,�C��) Mailing Address: Engineer: — it Phone: t�► Mailing Address: PROJECT NAME_ SND (.OG4l10_N JobAddress: 441A` Assessor's Parcel Number:1+1 1 Su -1b.-51 �- Lot 3 Block Building or Service Type: , `= LWM 0 L#Bedrooms: � Garbage Grinder Distance to Nearest Community Sewer System: N IIA Was an effort made to connect to the Community Sewer System: N Type of.OWiS Septic Tank ❑ Aeration Plant ❑ Vault ❑ Vaul[Privy _ 0 Composting Toilet ❑ Recycling, Potable Use ❑ Recycling ' ❑ Pit Privy 13 Incineration Toilet ❑ Chemical Toilet 1 ❑ Other Ground Conditions i Depth to 1 Ground water table I Percent Ground Slope Final Disposal by ❑ absorption trench, Bed or Pit Underground Dispersal ❑ Above Ground Dispersal ❑ Evapotranspiration ❑ Wastewater Pond j ❑ Sand Filter ❑ other - Water Source & Type Well I ❑ Spring ❑ Stream or Creek C! Gstern ❑ Community Water System Name_ Effluent l Will Effluent be discharged directly into waters of the State? 13Yes No (3RTIM(ATION 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 t e required information which is correct and accurate to the best of my knowledge. Property Ow er t and Sign Date OFFIiC+A _FJ IDNISY Special Conditions: / E,09ibel/ m',VCS19N!Slllsf /�CC.otNbOr�!"1 ?S `JYd f5 %/r��/ylfl'1 S f Permit Fee: 123• cc Perk Fee -Tota! 1. Fees- + _3. n° Fees Paid: I23 . ao Building Permit r 20 Septic Permit: SF:T : 14 3 Issue Date::: Balance Due: BLDG DIV: � 'u"''� J 019 APPROVAL DTE PA. * JV3.` b vis&, * M 15 f 1a