HomeMy WebLinkAboutApplicationGarfield County
Canmunity Development Department
108 8th 3reet , 3.Jite 401
Genwocd ~rings, ffi81601
(970) 945-8212
www .qarfi eld-count y. com
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r W.~New Installation ____ ___,__ .AJteration ---~-~---FAN \;_~ke-~
L DNellin Transient Use -~--Can--m-/lndustrial , Non~IJcffiest ic I
l~ibe I
INVOLVED PARTl ES
R"operty ONner: -'-""'"'-.L...!...:l.....__4-'-.1...'-'.~"'-'-'"'--------R"lone : (77o ) -c: ·-2.
Mailinghldre5S: Po ~i3 c><. 3 /~ G=h~V\ '-~.:rxv\. -::;'fr,'~g c;, 1)/602
Cbntrador: R"lone: ( ) _______
1
I Mailinghldre5S: ---------------------------
Blgneer: __________________ Alone: ( __ ...J ______ _
Mailinghldre5S: ---------------------------
L~NAMEANDL~llC?N{ ______ 1 --·--
1 ..bb Mdress: L-c:"...... e
Assessor's Parcel Number : ~3'j3~3S""/-06 ·o~3.Jb . ________ Lot Block
B.Jilding or Service Type: R-e..c;, ,•J.e.n_,,. #Bedrooms: "f3 Garbage Qinder _/_
Ost ance to Nearest Canmunity S:lwer 3jstem: -+)~LN\..~,_.;_\4--c...__ ______ .,.--____ _
Type of lffiS ~r-=~:~:''"~~ +"'~~ Pi~aM~b.~:,:~'"•~=
Olemlca Toilet a her ---------------
Qound Cbnditions I Depth to 1 Qoundwater table 1 Percent Ground Sope _____ _
Anal Osposal by ! A so rption trench , Bed o I
1
Lilderground Di spersal Above Qound Dispersal
Wastewater Pond Scrld Riter
aher _____________________ _
Water S:x.lrce & Type f._@-L_ ~ring _ S~eam or Qeek . [
1 CbmmunityWater ~stem Name ----------------
astern
Hfluent Will Efflue nt be discharged directl y into waters of the 3 a e? Yes
ClRTlR rn llON
iDPJicantaa<nowledgestFial the completeness of the appllcaf1on IS condmonal upon suCh fUrffier
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 oft he evaluation
oft he application; and the i95Uance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and reg.~lations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to bet rue and
correct to the best of my knowledge and belief and are desgned 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 under5tand 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 ad ion for perjury
1 as provided bylaw.
I hereby acknowledge that I have read and under5tand the Notice and certification above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
6e9Ja
a=FIOAL US::a.JLY
~edal Conditions:
~k Fee: .9J2_
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Fees Paid:
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