HomeMy WebLinkAboutApplicationcG Garfield County
Community Development Department
108 9th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
I TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
~New lnstall_at_io_n ________ O Alteration _______ 0 Re ~air
WASTE TYPE
ID Dwelling -~D-T_r_a-nsient Use
I
D Other Describe ----------------------------~
I D Comm./lndustrial D Non-Domestic
~ IN~OLVED PARTIES --
Property Owner: t )n d.V M D J S:%1C.+ M tU ftt.. Phone: ( 1 f7D
Mailing Address: 'to5 Wt '-L-1i1/ff. B1El.fS (,;/ <j/(g r;. t)
Contractor: 42, 1M p n::M.tt.s We. Phone: ( ci?o ) 4'.:\S-;;,3 '17
v1&ro Mailing Address: l'i7zt k t RfotF Rt?
Engineer: __ w_-.... 6-z ........ m ....... _ ..... K .... H« ........ 1=p--1C .... F:..-C.~>'-------Phone: ( T?o ){;.~ 'l7 Zt{
MaiHngAddress :_~~-~~~~~~~~~~~J~•~~~R~~~,~~~D~~~t~~~~~~~~ I
I PROJECT NAME AND LOCATION ---~
Job Address : ft>1J -4' ifa . ~11' Ria£ ?2, S[l46D --1
______ Sub . l\o,;:_ 5ub /iiatfmovt ot __ Block l Assessor's Parcel Number:
Building or Service Type: &MM EA.All R lk$tbr®AL #Bedrooms: _ _.3..__ __ Garbage Grinder L
Distance to Nearest Community Sewer System: _...;{J.,.,v..,.1<.__.J)b,.__~ ........ --------------
Was an effort made to connect to the Community Sewer System:___. .......... __________ _
Type ofOWTS Ji Septic Tank-CJ Aeration Plant D Vault D Vault Privy D Composting Toilet
D Recycling, Potable Use 0 Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet D Other _______________ _
Ground Conditions I Depth to 1• Ground water table Percent Ground Slope ------
Final Disposal by Absorption trench, Bed or Pit D Underground Dispersal D Above Ground Dispersal
D Was~ter Pond D Sand Fiiter ~
D Other ______________________ _
Water Source & Type 'fl Well J D Spring L D Stream or Creek D Cistern
_J D Community Water System Name -----
Effluent l Will Effluent be discharged directly Into waters of the State? D Yes
D Evapotransplratlon
pl No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such fu rther
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
I
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.
~ ~a/.w1s--~andsign Date
OFFICIAL USE ONLY
Permit Fee: OO
$1 B.
Building Permit Septic Permit:
Total Fees: 00 $;i .
Issue Date:
S·B·l5
Balance Due: ,00
BLDG DIV: -~Li~~' ~ar151-~-=~-~--~-"-/-=..,1.~:...._~ __ '_"_4
_ .. _~-------> >
APPROVAL
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