Loading...
HomeMy WebLinkAboutApplicationGafrfw1d County Community Development Department 108 8"' Street, Suite 401 Glenwood Springs, CO 81601 1970) 945-9212 www.garfleld-county.com TYPE OF CONSTRUCTION_ ❑ New installation WASTE TYPE © _Dwelling , ❑ Transient_ Use []Other Describe INVOLVED PARTIES Property owner; Mark s Msten Fam Mailing Address: 7207GRIODCarbw". G081623 Email Address: mark4—tr1kh4y.eum Contractor: MSA Fav 0 Alteration T M Repair ❑ Comm./Industrial ❑ Non -Domestic Phone: 003)45a.17'e Phone: ([303)4594P.79 Mailing Address: 7207 CR 100 carbmdwa. CO 01623 Email Address. maAeg—M'kluy-cam Engineer; Tadwbhe. c-* Ag-1 Phone: Q970)94s- '4 Mailing Address: +9s w um s0tive cO6le50 Email Address: wh"*@Wii#*0De LYow PROJECT NAME AND LOCATION Job Address: 7497 cR 1(MC&bw4W. co s1e23 Assessor's Parcel Number: 2391169UW36 Lot 12 Block Building or Service Type: R-wour 1 #Bedrooms: s Garbage Disposal{Y/N) Y Distance to Nearest Community Sewer System: smis- was an effort made to connect to the Community Sewer Systern: Not --MbW Type of OWTS m septic Tank © Aeration Plant O Vault ❑ Vault PriW Composting Toilet 13 Recycling, Potable Use ❑ Recycling I 0 Pit Privy 0 Incineration Toilet 0 ChemicalTollet b Other Ground Conditions Depth to In Ground water table 1W *01 dptri i Percent Ground Slope Final Disposal by 12 Absorption trench, Bed or Pit Gl Underground Dispersal 13 Above Ground Dispersal 0 Evapotranspiration ❑ wastewater Pond O Sand Filter ❑ rather Water Source 8r Type M well O Spring u 0 Stream or Creek CI Cistern ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters of the state? 0 yes 0 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 he 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. ZYl2.tiW13 Wti Property Owner Print and ig Date OFFICIAL USE ONLY Pd $ 7S. -s cc 671'L4: '202( cgr�> Special Conditions: Permit Fee: OG Perk Fee: TotalFees: Fees Paid: Ouilding Permit Septic Permit: Issue Date: Balance Du : �►itanv�niren¢a-triarsreta: Signed Approval Date