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HomeMy WebLinkAboutApplicationGarfield County Community Development Department 108 8'' Street, Suite 401 OCA �� 1p�6 Glenwood Springs, CO 81601 (970)94S -8x12 www.izarfield-county.com TYPE OF CONSTRUCTION New Installation c ❑ Alteration WASTE TYPE j ❑ Dwelling CI Transient Use ❑ Comm./Industrial Other Describe © Repair ❑ Non -Domestic INVOLVED PARTIES Property Owner. + / + r/ r phone: ( ;b ) 2! 7 2 Mailing Address: `9'6 JJI<w (JJrw li�rl5 Cy 19'/441 Contractor: Phone: �) Mailing Address: Engineer:igvvt je puri O t 1, Phone: �' 7 q- -2 ~ {3 2r Mailing Address: -3 PROJECT NAME AND LOCATION Job Address: Assessor's Parcel Number: �' �f £ U I y Sub. Lott Block Building or Service Type: A lo,% f A7 jpV? #Bedrooms:. ? Garbage Grinder ja Distance to Nearest Community Se er System: Was an effort made to con ect to the Community Sewer System: 42!:k Type of OWTS Septic Tank 13 Aeration Plant ❑ Vault ❑ Vault Privy ❑ Composting Toilet ❑ Recycling, Potable Use- F❑ Recycling ❑ Pit Privy ❑ Incineration Toilet C❑ Chemical Tollet ❑ other Ground Conditions Depth to s Ground water table Percent Ground Slope TJ'Z !Z Final Disposal by Water Source & Type Absorption trench, Bed or Pit ❑ Undergroui ❑ Evapotranspiration ❑ Wastewater Pond Other ❑ Spring 1 ❑ Stream or Geek Community Water System Name Dispersal i ❑ Above Ground Dispersal 0 Sand (Filter ❑ Cistern Effluent :. - Will Effluent be discharged directly into waters of the State? 0 Yes 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. Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: 123.oa Perk Fee: M &. Total Fees: A UD I V Fees Paid: 60 Building Permit Septic Permit:`], Issue Date: Balance Due: BLDG DIV: '� 1 `&w2 APPR VAI. DATE pd• t Iz3.�, Com, IoIW:VI I(a