HomeMy WebLinkAboutApplication.pdfGarfield County
AUG 1 ~) zo ~ommunity Development Department
108 8th Street, Suite 401
GARF IELD COUNTY Glenwood Springs, co 81601
1MMUNITY DEVELOPMENT 970 945-8212
www. arfield-count .com
TYPE OF CONSTRUCTION
D New Installation I • Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I • Repair
• Dwelling I D Transient Use I D Comm/Industrial l D Non-Domestic
0 Other Describe
INVOLVED PARTIES
Property owner :lt_a._w_t_e_1J_C._~-r,~9er 411.i£7:i'sa:-ft'11ge.r Phone: ( 7zo ) 2 -zo-qoo
Malling Address: 2€,2./ Co1nffj A.ON:f 100, w.ko~e. co <llb2'g
Contractor: ~ "IVtd. •" ~ r11t-f'1res Phone: ('170 )S7't-8"e>02.
Malling Address: f>O 80-,t ~Ott 1 Ciul:i.t>Ndttle.1 CE> K lb ~'3
PROJECT NAME AND LOCATION
JobAddress: 2b'2.l C.ocJN c;;;:;/! /0()
Assessor's Parcel Number:22'f / .. 31'3·0D.lJ~bSalt.Sec. ll, "175. Ri7Wi.:t b ,..
Building or Service Type: Bee 1'&.e1JU!.. #Bedrooms:1:e.":t:~ H~~~gage Grinder 0
Distance to Nearest Community Sewer System: _S_"'"""M"-1 ... '/ef~--------------
Was an effort made to connect to the Community Sewer System : --'-N....;..._o _________ _
TypeofOWTS • Septic Tank D Aeration Plant D Vault D Vault Privy D Composting Toilet
D Recycling, Potable Use D Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet
Ground Conditions
Final Disposal by 0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
0 Sand Filter
Water Source & Type • Well D Cistern
f--=----'------'---~·-----'-------------1 0 Community Water System Name _______________ _
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes No
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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 sa me for purposes of issuing the permit applied for herein. I
further understand that any fal si fi ca tion or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon sa id 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 inform~ion which lsjorre.~t and accurate to the best of my knowledge.
LAIAJi.EAJl.E r ING-ea. t!""~ ~ A-(..11 (.)~ t-r2, '2 D ll(
LISA S:/l\/(}E~ N.fA ~1'£je,..., i\vqust I:?( 20Jl/
Property Owner Print and Sign Date
OFFICIAL USE ONLY
~;;1;;;;s~e/kd" /l;P'f/,Lt>V,t/ f2¥yf ;€'eybl /;Jr ccyp11,,1/ /#~~th~
Permit FK. O () PerkFee: ¢ Total Fees: i-r· {) Q Fees Paid : ~.[)Q
Bule'g Permit 4 sWf~m ~3 44 Issue Date: Balance Due :
G E>-33 3
BLDG DIV: /{{~~~ 8/$.>/4-
APPROVAL D~TE /"