HomeMy WebLinkAboutApplicationCommunity Development Department
108 81" Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
TYPE OF CONSTRUCTION
• New Installation
WASTE TYPE
1 Dwelling 1 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
INVOLVED PARTIES
Property Owner: Pie --4-4
Mailing Address: ,
0 Repair
❑ Comm/Industrial I 0 Non -Domestic
Phone: ( )'87-1-} ?SA
a 3
Contractor:
--S71-, 01 to
Phone:
Mailing Address:
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: Z: ; et
Assessor's Parcel Numbd
Building or Service Type:
{� �} Sub.
rl r-a�.
Lot Block
#Bedrooms: _ 7 Garbage Grinderjl.'
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
ii Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1u Ground water table
Percent Ground Slope
Final Disposal by
❑ Absorption trench, Bed or Pit I 0 Underground Dispersal
❑ Evapotranspiration f 0 Wastewater Pond r 0 Sand Filter
❑ Other
0 Above Ground Dispersal
Water Source & Type Well 1 0 Spring 0 Stream or Creek 0 Cistern
0 Community Water System Name
Effluent I Will Effluent be discharged directly into waters of the State? 0 Yes lig No
1CERTIFICATION
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.
1 hereby acknowledge that I have read and understan, the, Notice and Certification above as well as
have p vided t o required informatiori w)ich
i
ee r: #7
Property Owner Print and Sign
accurate to the best of my knowledge.
OFFICIAL USE ONLY
Special Conditions:
Per it Fee:
I2S.—
Perk Fee: 00
1)150.
Tot I Fees:
d TS.
Fees Paid: Oo
ZSar43.
Building Permit
T- 3(&
Septic Permit: r�
epE Sai(tiC
Issue Date
C11Ctc
Balance Du
ne®
6�lJ f if
BLDG DIV: �'�""4
APPROVAL DATE
-
' * 5034