HomeMy WebLinkAboutApplicationRECEIvt Garfield County
Spy ,7I5
Community Development Department
GARFIELD COUNTY 108 8th Street, Suite 401
)MMUNI Y DEVELOPMENT Glenwood Springs, CO 81601
(970) 945-8212
www.garfi:eld-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
OF CONSTRUCTION
Property Owner: : ' i r .� i Phone: ( O722 ) cif 4,4 3' P
Mailing Address: PG -13o x( _ft" 4i'L- J C4 7L 4, (v • y--/ 61/ 7
TYPE
New Installation
0 Alteration
0
Repair
WASTE TYPE
PROJECT NAME AND LOCATION
Job Address: C1 6e -A__ / g: +
ig Dwelling 0 Transient Use
0 Comm./Industrial
Distance to Nearest Community Sewer System: ,V4
0 Non -Domestic
Other Describe
Type of OWTS
I$ Septic Tank i 0 Aeration Plant
0 Vault L 0 Vault Privy I 0 Composting Toilet
❑ Recycling, Potable Use I 0 Recycling
t
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet i 0 Other
INVOLVED PARTIES
Property Owner: : ' i r .� i Phone: ( O722 ) cif 4,4 3' P
Mailing Address: PG -13o x( _ft" 4i'L- J C4 7L 4, (v • y--/ 61/ 7
Contractor:RA.u`s : G.A.Av02 _ Phone: (9 70 ) 3G.$ z -
,9"2.4/-
Mailing Address: «~e-,.- 1.1-4 SG /t)&70 S -- 20 L. .�/6a'-,/ 7
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: C1 6e -A__ / g: +
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: 1)14%t%iik/ #Bedrooms: 3 Garbage Grinder jI
Distance to Nearest Community Sewer System: ,V4
Was an effort made to connect to the Community Sewer System: N4
Type of OWTS
I$ Septic Tank i 0 Aeration Plant
0 Vault L 0 Vault Privy I 0 Composting Toilet
❑ Recycling, Potable Use I 0 Recycling
t
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet i 0 Other
I
Ground Conditions
Depth to ft Ground water table
Percent Ground Slope
Final Disposal by
0 Absorption trench, Bed or Pit
J, , Underground Dispersal
0 Above Ground Dispersal
0 Evapotranspiration
0 Wastewater Pond
0 Sand Filter
0 Other
Water Source & Type
II Well
0 Spring
0 Stream or Creek
0 Cistern
0 Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes NI 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. 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.
Property Owner Prir<t and Sign
5 - L1-- Po fs_"
bate
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123.0
Perk Fee:
10. ac•
Total Fees:
`M. 01)
Fees Paid:
1/74'3.0a
Building Permit
Bye -5013
Septic Permit:
SOFT -S(031
SST- 3(031
Issue a
S 4.
lc116
Balance due:
BLDG DIV: it.
7` S 45'PA
PROVAL ATE
* _ 1 _ . - 1
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