HomeMy WebLinkAboutApplication. '
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
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TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
!tiJ. New Installation I D Alteration I [J Repair
WASTE TYPE --D!I Dwelling l D Transient Use I d Comm/Industrial I D Non-Domestic
D Other Describe -
Property owner: --r.:;;c r 7 ~ u o h "'.,..,a ev c;.. Phone: ( q2 Cl > 512 2 -<.{R ri. [lNVOLVEDPARTIES _ _ --------------------1
Mailing Address: I() 0 ~ .4 ,_k_ 1-.Jy t: IJr /--&. .... w ~ <£:.pr °'1S Co ~I fl I
Contractor: __ 0""-=W'-"<.LH:e-.:::..:....._ ____________ Phone: I 97u ) 3 f1"J-l{?rL l .
Mailing Address: /6 of5' /ls,_k. W-ut= t?v. lr/y. ..1,,J $pdhjr ?a c?!!{d I
Engineer: ___________________ Phone:(._ __ ,, ______ _
Malling Address=----------------------------
PROJECT NAME AND LOCATION
JobAddress:_....1......w....i~-~~:......;.~-.(1:......i.u:.;io,&.~...w;.....,~~~~~~---------~
Assessor's Parcel Number: ;;?3 '1S -llJctKfu'f;! 5 .orl~~ t°JJ.ot di Block
Building or Service Type: V. L. ' r/ J~#;.:drooms: '-'/ Garbage Grinder_
I Distance to Nearest Community Sewer System:......_....,.... ........ ______________ _
Was an effort made to connect to the Community
TypeofOWTS &I Septic Tank C Aeration Plant C Vault C Vault Privy C Compostln1 Toilet
C Recycling, Potable Use 0 Recycling C Pit Privy C lndneratlon Toilet
C Chemical Toilet
Ground Conditions Depth to 1 Ground water table----Percent Ground Slope ------
Final Disposal by C Absorption trench, Bed or Pit , C Undel'lround Dispersal -0 Above Ground Dlspersal
C Evapotransplmlon 0 Wastewater Pond C Sand Filter
COthu _____________________________ __
Water Source & Type C Well C Spring C Stream or Creek
Community Water System Name _____________________ __
Effluent Will Effluent be dlKhal'led directly Into waters of the State? C Yes ~No
.. f 0 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. 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
have provided t"quired Information which is correct and accurate to the best of my knowledge.
~ ~ --;;_ vr.., "i!-u..c '""· Jc..c "' 3 I 13 I 6
~wner Print and Sign Date r1
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
~l'J ~ Perk Fee: E N Cz"
Building Permit
'Po.ld 'b-\ '3 · \S
$03. se. ~ * 46 8':l4
Total Fees:
~ 00 Fees Paid:
~/;JI].. oo
-\S
DATE I