HomeMy WebLinkAboutApplicationINVOLVED PARTIES
Property Owner: CRi _ S Hl _ Phone: ( C1 To ) 6(B — 3 3-3-1
Mailing Address: Q 0 fox tAuprn spf6 CQ b az
Contractor: s S its Phone: (
Mailing Address:
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Engineer: I•
Mailing Address:
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Phone: ( )
Cleo wood Cpfir
PROJECT NAME AND LOCATION
Job Address: 16 D Cruv,Qd 1 Il- or- 61--140 rSc 5i r
Assessor's Parcel Number: '23`15 2b7- '3° u Z Sub. �' n c{
Building or Service Type: R.c.S c4 6+44 el 1
#Bedrooms:
Distance to Nearest Community Sewer System: 2. kS
3
Lot 3 Block
Garbage Grinder LS
Was an effort made to connect to the Community Sewer System:
NO
Type of OWTS
Septic Tank 0 Aeration Plant 0 Vault D Vault Privy 0 Composting Toilet
O Recycling, Potable Use D Recyding D Pit Privy 0 Indneration Toilet
O Chemical Toilet 0 Other
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
ONSITE WASTEWATER
I�:��;��►�I*l Il SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
I: 181, New Installation
WASTE TYPE
❑ Alteration
Dwelling L❑ Transient Use
0 Repair
❑ Comm/Industrial 0 Non -Domestic
1 0 Other Describe
Ground Conditions
Depth to 11` Ground water table
Percent Ground Slope ...
Final Disposal by
Water Source & Type
O Absorption trench, Bed or Pit 0 Underground Dispersal 0
O Evapotranspiration
O Other
0 Wastewater Pond 0 Sand Filter
1. Well 0 Spring 0 Stream or Creek
O Community Water System Name
0 Cistern
Above Ground Dispersal
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes IR 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
have provided the requireformation which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
3_zq-15
Date
OFFICIAL USE ONLY
Spedal Conditions:
Permit Fee:
/z3, 00
Perk Fee•Total
e./UCj
Fees:
/Z5./0
Fees Paid:
I-2-3. to
Building Permit_�
Septic Permit:
3s-gi
Issue Date:
Balance Due:
BLDG DIV: 'ef9--r-1.4.
4 6 if
APPROVAL
ATE
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