HomeMy WebLinkAboutApplicationGarfield County
1
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-countv.com
TYPE OF CONSTRUCTION
ILK -New installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
leDwelling 0 Transient Use 0 Comm/Industrial
0 Other Describe
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: 1kt.11.k VlakAvv eo. Phone: fila_) o 1 ? ON Z
Mailing Address: 7416 'i-1 °Waal Xre- t c -e- (0 Sr 513
Contractor:
Phone: �1 (Ot
Mailing Address: )-41.c.) V-intALi-ri A- 1alt. CO Cada
Engineer:
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:' TC:$13 S . 1•11e5,r 1(. SL (-1- C o l' l05
Assessor's Parcel Number: Sub. SLtf\ PAUL/Act-1S Lot 25 Block
—
#Bedrooms: 4 Garbage Grinder I_
Phone: (
Building or Service Type: k -1-00"-e_
Distance
tta0".e-
Distance to Nearest Community Sewer System: 0N'�
Was an effort made to connect to the Community Sewer System: WO
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
SepticTank 0 Aeration Plant 0 Vault 0 Vault Privy 0
Composting Toilet
❑ Recycling, Potable Use ❑ Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other [ice /'s/d
Depth to In Ground water table Percent Ground Slope
❑ Absorption trench, Bed or Pit liketderground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
❑ Well 0 Spring 0 Stream or Creek 0 Cistern
ISKCommunity Water System Name 4)1AA 11-1136.110 I4Pl.( Ni c itS5OO
Will Effluent be discharged directly into waters of the State? 0 Yes IFI4o
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. 1
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 required information which is correct and accurate to the best of my knowledge.
/ 4 �,.
Property 0 er Print and Sign y _ ues-
¥- e a.4 l$es
OFFICIAL USE ONLY
Lit I,c
Date
Special Conditions:
Permit Fee:
113 .co
Perk Fee:
5o.00
Total Fees:
2 3.00
Fees Paid:
123. CO
Building Permit
g —31It
BLDG DIV:
Septic Permit:
3eoi
Issue te:
S
Balance Due:
150.00