HomeMy WebLinkAboutApplicationo
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
0 New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
WfTE TYPE
Dwelling
0 Transient Use
Repair
Comm/Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES 'fir ��
Property Owner: 1 L1 /7J�V z / ' O
Mailing Address: 37/P 2 I i/ y 2-cti a...�
Contractor: if) 1-1.1% _ 711.14-rI UAL -t_> Phone: ( )_
Mailing Address:
Phone: ( 1 . 71 ` _ 1
8/60/
Engineer:
PhonePhone:ig717-07,47- /
Mailing Address: 33 4 ItAtert Dr, z /C'DALE,J ' ?
PROJECT NAME AND LOCATION
Job Address: 31(, SLS
93c)- / IL2
Assessor's Parcel Number: / S5d. d c (22W Lot Block
Building or Service Type: /Milt r eel ar #Bedrooms: Garbage Grinder 7 --
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: A or 1)c A r3L-1
Type of OWTS
EiSeptic Tank L0 Aeration Plant I 0 Vault I 0 Vault Privy 0 Composting Toilet
O Recycling, Potable Use ❑ Recycling T 0 Pit Privy I 0 incineration Toilet
O Chemical Toilet I 0 Other
Ground Conditions
Final Disposal by
Depth to et Ground water table
OaAbsorption trench, Bed or Pit
Percent Ground Slope
O Evapotranspiration
0 Underground Dispersal 0 Above Ground Dispersal
0 Wastewater Pond 0 Sand Filter
O yer
Water Source & Type ®'Well 1 ❑ Spring 0 Stream or Creek
Effluent
0 Cistern
O Community Water System Name _
Will Effluent be discharged directly into waters of the State? 0 Yes 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.
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.
,,�1 LL ,LIVE
Property Owner Print and Sign
3—
Date --
Date
OFFICIAL USE ONLY
Special Conditions:
Permit F
Perk Fee:
Total ees:
Fees Paid:
Building Permit
- -
Septic Permit:
Issue Date:
3- I — f C
Balance Due:
iiii3c(-6.
".A
3.'2'
BLDG DIV: 1111/4
2_ 01
•�DATE
AP' RO •
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