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Garfield County l
WASTEWPE
[1 Dwelllng
El other Describe
E¡ Alteration
E Comm/lndustrlal
Communlty Developrnent Department
lo8 8th Street, Suite 401
Glenwood Springs, CO 81601
1970) 94s-8212
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TYPE OFCONSTRUCTION
E New lnstallation E Repair
Non-DomesticE Transient Use
INVOLVED PARTIES
Pfoperty Owner: Steven and Balley Haines Phone: ( 970 ) 903-3892 .. ¡
Malling Address: 18 Pln€ Slr€et. Carbondsle, cO 81623
Cöntractor: Steven Hainee Phone:(970 )9093892
Malllng Address: 18 co 81623
Englneer:
Mallinß Address:
PROJECT NAME AND TOCATION
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Phonel s7€778-s81S
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Job Address:41 S, Prne titreet
Assessol's Parcel Number: 239328313016 Sub, COOPERTONTVVNSTE. Lot 5 g¡ock l3
Bulldlng or Servlce Typel Dwelling #Bed¡ooms: 4 Garbage Grinder 0
Distance to Nearest Community Sewer System:112 mile
Wa¡ an effort made to connect to the Communlty Sewer System: Yes - Town of Ga¡bondale sald no
Type of ISDS ¡ Sepllc Tank tl Asralion Plent E vault D vault Prlvy tr Compostlng Toilet
E Recycllng,Pot¡blsuse E Recycllng tr PhPrlW E lnclneratlonTollet
E Chemlcal Toilet E other
Depth to 1'r Ground weter table j[- Pêrcent Glound Slope 0
E Absorpt¡on tr€nch, Bed or Plt Êl Und€tground Dlspêrsâl El Abovê G.ound DþpðÌsel
E Ëv¡polransplrâtlon E Wastewãler Po'ld Ð Sand Fllter
Ground condlt¡ons
Final Dlsposal by
Ël other 6o-. n .t 13.-c-r.rx-( úl.c 5a-{} * I (r*.-À
Water Source & Type E Well E Sprlng El Sl¡eam or creek n clstein
E Commun¡ty Wåter Systom ¡lems
INDIVIDUAL SEWAGE
DIsPOSAL SYSTEM
(rsDs)
PERMIT APPLICATION
Ëffluent Wlll Effluent be dlscharged dlreæly ¡nto weters of th€ State? El Yes ã No
CERTIFrcANON
*lJ..il.j,î,^l.j{fyjåi,s,"ï,1T¡,,ÌT^iåË1",8î:'å3iiËåiT,,,åå'Bili,:Tliåi!:!Ë1q"4,!Ti[,l,.fH!:^-
tlifl'"ilËÏHllil'f,li.*siLl,'zuiF',.fl¡$.*"'fiii't[[*il¡:rgl;::'"rrfff,,:l'8i".1öi!"'
necessarv to ¡nrrr".orpliii.Ë'*äll-*iä;ånå ;eàYÈtiı'nsmade,lnformation and.reports submitted
fi:äïi,'jñiïã;l,j¿d t6 Ë tï¡äìiiàã uv tlìã ap-piicant are or will be rep.resented to be true and
;"ïäiäîh:'bìiî';i;'üd"illãää;äd LÀiiãiåiJãrà ueslened to be rélied on bv the.local
ilïíTnäi?l:;à\[rix#',:ltåilffii";*lïrj#,gs;ff'g;'iliir;1,!,ii"fi!åËri:ÌillilT"'n '
aoolication or revocetion ;í¿ift*ñft A;añt*d-úsea upon said ipplication and legal actlon for perjury
ai'provided by law.
lherebyacknowledgethatlhavereadandunderstendtheNotlceand
have provided the required lnformatlon whlch ls correct and accu¡ate to
\t.^.'*,
Certiflcatlon above as well as
the best of my knowledge.
s
Date
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Property Owncr Prlnt and Slgn
OFFIGIAT USE ONIY Pó ?l é;.h",cî, oø/t
Spe(¡ål Condltlonsl
Perft Fee:Permlt
BalanccSÊptlc Pormltt
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DAfEAPPROVAT
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