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HomeMy WebLinkAboutApplicationCommunity Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.earfield-county.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION ,, New Installation WASTE TYPE -. Dwelling ❑ Transient Use ❑ Other Describe 0 Alteration 0 Repair 0 Comm/Industrial 0 Non -Domestic INVOLVED PARTIES `� Property Owner -To rno5 4 tile-KoatlPd((��`npP1)3 Phone: f 7+ ? C/ S 7-- a i 1 Mailing AddressP() , (- )C ~7 O R ti4- . C o , 9/ Contractor: ,wo S 141 5 o , Phone: (Y O) G..S LL Mailing Address: P S TN,C 0. 1 Cor -S -C) Engineer: Phone: ( Mailing Address: PROJECT NAME AND LOCATION Job Address: —Tr-) Irv-) 1 Assessor's Parcel Number: Q 137-a9q` UD (Sub. Lot Block eae 337,. Building or Service Type: rfl c. uk \r\O n(1Q #Bedrooms: Garbage Grinder Distance to Nearest Community Sewer System: I\ .. S Was an effort made to connect to the Community Sewer System: Type of OWTS 1E( Septic Tank 0 Aeration Plant 0 Vault ❑ Recycling, Potable Use 0 Recycling ❑ Chemical Toilet 0 Other 0 Vault Privy 0 Composting Toilet 0 Pit Privy 0 Incineration Toilet Ground Conditions Final Disposal by Depth to 1" Ground water table Absorption trench, Bed or Pit Percent Ground Slope 0 Underground Dispersal ❑ Evapotranspiration 0 Wastewater Pond ❑ Other Water Source & Type %Well 0 Spring 0 Stream or Creek ❑ Community Water System Name O Above Ground Dispersal 0 Sand Filter ❑ Cistern Effluent 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 1 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. •,0•1 e 5 et ▪ -54›., roperty Owner P- rint and 1 2, Date OFFICIAL USE ONLY �1 Spedal Conditions: Permit Fee: 1i 00 Perk Fee: jST•I�t? Total Fees: °2--.3 UD Fees Paid I� -7 `QD Building Permit M�-' (9 Septic Permit: te` 359Th Issue Issue Pate: Balance Due: / /J BLDG DIV: .- APPROVAL DATE 4n-3 DD) ✓ l7-21 qi315"