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HomeMy WebLinkAboutApplicationGarfield County unity Development Department 108 9th Street, Suite 401 SEP 2 6 ZOU Glenwood Springs, CO 81601 GARFIE LD co uN·rY . (970) 945-8212 )MMUNln' OEVELOPMEt--.'Www.garfjeld-countv.com TYPE OF CONSTRUc:TION 0 New Installation I i;;a' Alteration WASTE TYPE ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION I ~ Repair i;;r-Dwelling J 0 Transient Use 0 Comm/Industrial I 0 Non-Domesti c --- 0 Other Describe INVOLVED PARTIES Property Owner: 7<.-6-,J-y;Jc_ Phone: ( 9 1tJ )t.:Z.5 -5 /n-- Mailing Address : PO K o r: :J. 5 1 KJ.f/ .,_ C:O ?J'/(,,~() Contractor: .A// Servi ·~ S:-e,12ft ~ I Phone: (91u ) 305 -.5.2.S9 Mailing Address: .33 /0,v )Jh ~.r-I ·fe iv~ PROJECT NAME AND LOCATION Job Address: -'0""-'"/....;~....;;;L __ -==.;._;.,H-....:....::~-""'-'--""'---L-.i.:.;..:=---"C-O=..;:....._ _ __.._.c..::t,:::...:::...;o=------------i Assessor's Parcel Number: _______ Sub.---------Lot ___ Block Building or Service Type:-----------#Bedrooms: ____ Garbage Grinder_ Distance to Nearest Community Sewer System:-------------------- w as an e ff ort ma d h e to?~t tot e Community Sewer System: I Type of OWTS ~ ...... D ~iific Tank I D Aeration Plant j D Vault j D Vault Privy j 0 Composting Toilet - D Recycling, Potable Use D Recycling j 0 Pit Privy I D Incineration Toilet -D Chemical Toilet D Other Ground Conditions Depth to 151 Ground water table Percent Ground Slope Final Disposal by D Absorption trench, Bed or Pit I 0 Underground Dispersal I D Above Ground Dispersal D Evapotranspiration D Wastewater Pond I 0 Sal)d Filter --D Other Water Source & Type D Well I 0 Spring I D Stream or Creek I D Cistern D Community Water System Name r Effluent Will Effluent be discharged directly into waters of the State? 0 Yes ~ No I 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 same for purposes of issuing the permit applied for herein. 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. OFFICIAL USE ONLY Balance Due: