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. ~ Ga~.field County
!/~ ~1 1 ~ • 1) ~ \_l!.OJl;I unity Deve opment Department
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS) -.l .. _ ..,.1 t1 v R 'J 1 os gth Street, Suite 401
OCT O ~i 201 4 Glenwood Springs, CO 81601
(970) 945-8212 PERMIT APPLICATION
GAt,F lr-t.tl c:1 )llNfY www.garfield-county.com
)MMLJr~1 Y r ·.1i~:1 ~iri,lENT
. TYPE OF CONSTRUCTION
B.. New Installation
' WASTETYPE
I D Alteration I D Repair
~/
D Dw elling I D Trans ient Use IA Comm/Industrial I D Non-Domestic
D Other Des cribe r \
INVOLVED PARTIES
Assessor's Parcel Number: 2.31'Il2 II 0Do t [ Sub. ______ , __
Building or Serv ice Type: t b ty\ f('Q,i__C( Cli!.~ #Bedrooms: 11\
Distance to Nearest Community Sewer System: __ + __ J_. _.yY).........,.,_l _l"""'V...._ _ __,... ______ _
Was an effort made to connect to the Community Sewer System:---+-"""'+__._....__ _______ _
TypeofOWTS Septic Tank D Aeration Plant D Vault D Vault Privy D Composti ng Toilet
D Recycling, Potable Use D Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet D
Ground Conditions
Final Disposal by D Underground Dispersal D Above Ground Dispe rsal
D Evapotranspiration D Sand Filter
D Other------------------------~
Water Source & Type ~Well D Spring D Stream or Creek D Cistern
D Community Water System Name-------------,..--,.----
Effluent Will Effluent be discharged directly into waters of the State? D Yes No
... ., .. ~~------
CERTIFICATION
Applicant acknowfedges that the completenes5 of the ap-plication is c onditional 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 evaluat ion
of the application; and the issuance of th e permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regu lations made, information and reports subm itted
herewith and required to be submitted by the appli cant are or will be represente d 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 falsifi cation or misrepre sentation may re sult in the denial of th e
application or revo catio n of any permit granted based upon said applica tion and legal act ion for perjury
as provided by law.
knowledge that I have read and understand the Notice and Certification above as well as
1ded the required information which is correct and accurate to the best of my knowledge.
Date r I
QFF.IGIAL USE ONLY
Special Conditions:
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DATE
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