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Garfield County
Community Development Department
tog 8" streêt, Suite ¿t{tl
Glenwood Springs, CO 81601
{970} 945-821ã
www,qarfield-countv.com
INDIVIDUAL SEWAGE
DISPOSAL sYsTEM
{tsDs}
PERMIT APPLICATION
TYPE OF CONSTRU T|{}N
tr New lnstallatisn fl Alteration E3 Repair
WASTË WPË
i/Dwelling E Transient Use tr Com ndustrial n Non-Domestic
El Other Describe
I!¡VOLVED PARTIËS
Property Ourner:?r*v and Bailev Phone:5i5 72t-CI039
Mailing Address;7919 G 76 New Virginia,IA 50210
Mailing Address:
Assessor/s parcet Number: 2l ss-291-0q-l0J :su¡. YggltaT sptîLeå5try!- l"ot *jl* Block N4*
Building sr Servlce Type; Residental.. *- - #Bedrooms: . 2
-Garbage
Grinder No
Was an effort made to connect to the Community Sewer System:
PROJE T NAME ANB LOCATION
)
No
Phone:
Phoner 1,97t l94s-8676Engineer:Hieh Country Ensineerins Inc
Mailing Address:l517 Blake A
Distance to Nearest Comrnrinity Sewer System:3 Miles
sc ClÌ f,l Álllsrrifê llìl Glenwnnd
Contractor:
"lob Address:R*acl 127
r'E Vault PrivyType of ISDS
I otherE Chemiral Toilet
E Composting Toilet
ü Recycling, Potãble Use Ël Recycling
Tank ü Aeration Plant
E lncineratlon ToiletE Plt Rrivy
Cl Vault
Percent Gro¡¡nd SlopeGround Conditisns ! neptl¡ to 1"t Ground water table Ncne
r'
I
Il
i
l
Final Disposalby
Water Scurce & Type
Ë Evapotransptrat¡on
trench, Bed or P¡t E Underground Dispersal E Above Ground Dirpersal
i fl Wastewater Pond
i
t Sand Filter
E! Spring ' [J Stream or Creek , E eistern
E Community Water SYstem rr¡ame N/A
Effluent Will Effluent be discharged directly ¡nto waters of the State? H Yes
n upon suconona
as provided by law
antacom
I hereby aeknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information which is correct and aecurate to the best of my knowledge.
,/ rÒ ,(-'lg
Prope Owner rint and Sign Date
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Special Conditions:.-
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Pernrit Fee:na Perk Fee:Total Fees:tâi Fees Paid:
l?5,å#gf'æ Sentic Permit:
-\trP+<53 ta "'"'fä7 ls / /q Balanee Due:
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BIDG DIV:&/5-2dB
DATE