HomeMy WebLinkAboutApplicationLe Garfield County
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V �i .�_ munity Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
JUL 3 1 Z01? (970) 945-8212
www.garfield-county.com
CONSTRUCTION
❑ New Installation
WASTE TYPE
❑ Dwelling ❑ Transient Use
❑ Other Describe
❑ Alteration
11 ❑ -Comm./Industrial
❑ Repair
❑ Non -Domestic
INVOLVED PARTIES �,�y _ i__
Property Owner: tf u ' �flo ' ' 1L1,- r o l LL—C,,Phone: ( y T
Mailing Address: SD C) � ✓ FL ywv
Email Address:
Contractor: IV Phone: (�_70 } ria _ a9_�q
Mailing Address: 14-3 ! f r f h
Email Address: �� LLrd D es eo
Engineer: _Km Cr�(L-Ilj 1 f—CC.Y < Phone:
Mailing Address:
Vail
Email Address:
PROJECT NAME AND LOCATION
Job Address: �✓
Assessor's Parcel Numbe 47NSY-4- _ub. Lot Block JJ
Building or Service Type: Rfs4)d)Pjn rt_. #Bedrooms: _ Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: O
Type of OWTS Septic Tank 1 C3Aeration PlantAL- i ❑ Vault ❑ Vault Privy Composting Toilet
❑ Recycling, Potable Use ❑ Recycling,, ❑ Pit Privy ❑ Incineration Toilet
❑ Chemical Toilet ❑ Other
Ground Conditions Depth to 11t Ground water table Percent Ground Slope
Final Disposal by Pk Absorption trench, Bed or Pit ❑ Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration ❑ Wastewater Pond j ❑ Sand Filter
❑ Other
Water Source &Type ❑Well E3- Spring 13 Stream or Creek Cistern
❑ Community Water System Name
Effluent ' 4 — Will Effluent be discharged directly into waters of the State? 13 Yes 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.
Property Owner Print and Sig Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
ooI-j
P k Fee: QD Total Fees:(30Fels
Paid:
0�
Building Permit
Septic Permit: Issue Date:
Balance Og:
BUILDING/ PLANNING DIVISION:
�—�-- 7
Signed Ap oval
Date
7 `3 I.1
v Iy 27& 00