HomeMy WebLinkAboutApplicationcG Garfield County
Community Development Department
108 gth Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
.I Ii~,
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
~ New Installation I D Alteration I D Repair
WASTE TYPE
18 Dwelling I D Transient Use I D Comm/Industrial I D Non-Domestic
D Other Describe
INVOLVED PARTIES.
Property Owner:_ C~(bw ~. Phone: (VO )....c..8o........,'-"'<-,~...,._--1
Malling Address: --=o-=n-=-..... Go ......... o ...... s. ..... e__,..l.w_.._,c.......,..., _....,G.....,,,,...'--'k""""-L.l ..... i._L._.G ..... D...........:~-...f"-lib~i:?.~?-----
Contractor: ........ L.W..-.....-a.:.~--i..wuc.a-iU..1:1.-.a..Li.a.1.-.::t::l[.Jlo:c~.1-----Phone: ( 910 ) 'Ul'· ?rl'J'l
Mailing Address: __..:.=...-""-~"""""" ....... __,""""".-..-.---'~=a=--r_./o...,c-.. ... "5J.""c.E.Ul e._,_r .... COa.c...._K......,Uc,......,.;L,._IL...-_____ _
Engineer: ~l.l-liC:::l~.i..-.....s.t.1"""-1~~......u~.f--~~LL.=..Jlu.ot..::!=t--Phone: (f"/O ) 80'? · S"',;l,rJ
Mailing Address: 3c '&ur (d\.,.,.j Dtj ~~ ~ CfJ cft6J-J
PROJECT NAME AND LOCATION
Assessor's Parcel Number: _______ Sub. Pi N)'ON P ..... J..<s Lot II Block
Building or Service Type: A/,a ~ #Bedrooms: _ _.'i._ __ Garbage Grinder _
Distance to Nearest Community Sewer System: ____ Al ....... A...._ ____________ _
Was an effort made to connect to the Community Sewer System: .... AA ...... .._ _________ _
TypeofOWTS J{ Septic Tank 0 Aeration Plant D Vault D Vault Privy D Composting Toilet
D Recyclfng, Potable Use D Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet D Other _______________ _
Ground Conditions Depth to 1 Ground water table-----Percent Ground Slope ------
Final Disposal by • Absorption trench, Bed or Pit D Underground Dispersal D Above Ground Dispersal
0 Evapotransplratlon D Wastewater Pond D Sand Fiiter
D Other _______________________ _
Water Source & Type D Well D Spring D Stream or Creek D Cistern
tircommunity Water System Name -----------------
Effluent Will Effluent be discharged directly Into waters of the State? D Yes a{ 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 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. 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
rrect and accurate to the best of my knowledge.
1!?11 I :?~I .r
' Date
OFFICIAL USE ONLY
Special Conditions:
Fees Paid: 06 ~l;J.13.
Permit Fee: $/Cl.~ .. ~
Perk Fee: Total Fees: tb/ 00
Building Permit Issue Date: Septic Permit: Balance Dua,
.2, •