HomeMy WebLinkAboutApplication11,CEIS117.
APR 1 1 + 20
GARFIELD COUNTY
�_ ftsi'�l]Ivl I Y nEvE 4PM Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
Garfield County
Lewh'iro
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New
❑ Installation Alteration
Repair
WASTE TYPE
Dwelling
0 Other Describe
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: t0 Y ZEN
Mailing Address: ( e:. 57-1
Contractor: > /1/1-T(.4
Mailing Address:
Phone: 7� )%
c1,/9%it/ Phone: (97v ) c6 (-
/ e 2S`G
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:, 'LT LU R$'/'
Assessor's Parcel Number:
Building or Service Type:
Sub. Lot Block
/740/'I/: #Bedrooms: 3 Garbage Grinder v
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank I ❑ Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
O Recycling, Potable Use— 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions
Depth to a Ground water table
Percent Ground Slope
Final Disposal by
Absorption trench. Bed or Pit 0 Underground Dispersal 0
❑ Evapotranspiration 0 Wastewater Pond I 0 Sand Filter
❑ O• ther
Water Source & Type ficiWell
Above Ground Dispersal
I 0 Spring
0 Stream or Creek
0 Cistern
❑ C• ommunity Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? le -1 -'es 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 required information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
y Q/s
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Perk Fee:
rit:
Iola! FFjees�: 00
Fees Paid:
Building Permit Septic Per
Qf 7 r/�V��
Issue
It
Date:
�
11S•
Balance D e6
iii
1 , NO. `f �
BLDG DIV: -41p,--2 0 - 'o/5
APPR• AL
DATE
Fd•��Soo, ✓#Ltq� 912011t