HomeMy WebLinkAboutApplication1111/rr&11k11 Garfield County Community Development Department 108 gth Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-countv.com 1 TYPE OF CONSTRUCTION tk New Installation WASTE TYPE ❑ _D_welling 0 Transient Use I7 Other Describe ONSITE WASTEWATER SYSTEM (OWTS) PERMIT APPLICATION 0 Alteration ❑ Repair Comm/Industrial ❑ Non -Domestic INVOLVED PARTIES Property Owner: 4 j.j Cr&r.A.A- -rk Cku,rc-I^ Phone: (q7b ) c-t+t-5--Sgf7Z Mailing Address: 1.fl. r2,cr. 1Gg( � bc'y., ,rx,ri SpPs4, C.D. P,ifn02 Contractor: M ouv C ,r o(r -Hoy% Cl, c,..r<Ai► Phone: (rl'7 ) q y-5 -59(17 Mailing Address: P.O. 9,cr* IGia57 r_. No let Lyon ri G,vri.un5/5 Cr'• 13i6n?_, Engineer: _.(21,lorct..dr) Riucc, Gr jtnE�i'iV� Phone: ( g70) l,? y_gg1 Mailing Address: P.U. p,< -,x 1301 R; - lc- c_c,. Fi I , 5Q PROJECT NAME AND LOCATION Job Address: 4- 47 {01 1r4NA/ N? t 2..4 C_ ir=tt.I-A."0 +1d S ening, Assessor's Parcel Number:2.42,g 15-2evoqg Sub. Lot Block Building or Service Type: PrCJ c t #Bedrooms: Garbage Grinder— Distance to Nearest Community Sewer System: 1 /A k ,hr+l.1,A Was an effort made to connect to the Community Sewer System: Type of OWTS is Septic Tank I 0 Aeration Plant I 0 Vault 1 0 Vault Privy I 0 Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy I 0 Incineration Toilet 1 0 Chemical Toilet I 0 Other Ground Conditions Depth to 1" Ground water table I Percent Ground Slope Final Disposal by Al Absorption trench, Bed or Pit 1 0 Underground Dispersal i 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter 0 Other Water Source & Type l& well 0 Spring 0 Stream or Creek 1 0 Cistern ❑ Community Water System Name Effluent Wilt Effluent be discharged directly into waters of the State? 0 Yes XI No Col c rcl d o awl ir)`.�r; vtY See cF��tie- . CERTIFICATION Apo iicant acknowledges that the completeness oTthe application is conditionaVupon 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 hich is correct and accurate to the best of my knowledge. Property Owner Print and Sig :Vie///c- Da Z %S Da e OFFICIAL USE ONLY Special Conditions. Per it��--Fyyee: CO 1/s4• Perk Fee: 'iota Fees: co l Fees Paid: CC + Building Permit Septic Permit: Issue Dat Balance Due: BLDG DIV: l rn � t/1. y/7:11 :.e W1 APPROVAL d---- . DhT( 715,:.a s .t 8.15 \\O r23.