HomeMy WebLinkAboutApplicationGarfield County
GARFIELD (,(;u,~ J 1
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
'. ·,u, J'."·TY l")f: :·-·/"\-••-L IT '" ~ ..... t •; Community Development Department
I
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
PERMIT APPLICATION
~EOFCO_N_ST_R_U_CT-IO-N--~~~~~---~~~--. -~-~~~==:J
~ New Installation D Alteration D Repair --------'-~ -----~----;, ~E~ -
l!:f Dwelling D Transient Use ___ CJ. Comm/lnduy _tr_ia_l __ __.__;;D Non-Domes_ti_c ___ .;
D Other Des;;:ibe ____________________________ _
-----------~
INVOLVED PARTIES
Property owner: JJmD#i~Tav L:ive Phone: ( 'i7 .:.}9'f.>-:75is·
Mailing Address : ,,3 1J'6 l:t?. 115" <,., l.CJ.ku.1?/) .sRar .. l\:.~ 4 Stt..o t
Contractor: ___________________ Phone:( ___ --------
Mailing Address =------------------------------
. --------Engineer: ___________________ Phone :(._ __ -------
Mailing Address =------------------------------
PROJECT NAME AND LOCATION
Job Address: 314c... Ut-ll i' 4 u:V..u.x:>~ .src-u & G. -21 £:.:;,\
Assessor's Parcel Number: cit9 !J lqULQ Ji{lSub. _Cg/._;. ~------tre?f_· .il,3 _Block
Building or Service Type : .:51 u ('f Bffl Ji #Bedrooms: _3'----Garbage Grinder l:!E
Distance to Nearest Community Sewer System: -~S'-.wm~;,;;;ff..:.\J--------~------
Was an effort made to connect to the Community Sewer System :-------------
TypeofOWTS B' Septic Tank . 0 Aeration Plant 0 Vault 0 Vault Privy ! 0 Composting Toilet
-----·-I D Recydlng, Potable Use I D Recyding ; a Pit Privy a lndneratlon Toilet
I ' I a ChemicalToilet I a Other _______________ _
Ground Conditions l Depth to 1 • Ground water table Percent Ground Slope ------
! Final Disposal by
I
~ !r Absorption trench, Bed or Pit I 0 Underground Dispersal D Above Ground Dispersal
i
I a Other------------------------
1-1 W-a-te_r_S_o_u-rc_e_&_T_y_p_e__.._. i!'°Well 0 Spring D Stream or Creek -C astern
I D Community Water System Name ________________ _
Effluent Wiii Effluent be discharged directly Into waters of the State? 0 Yes 0 No '
[aRi'IFICATION-:~ ~ ·~~ ~r-.-·--. --~
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.
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 Date
OFFICIAL USE ONLY
Special Conditions:
Perk Fee: _ -
l>O.
Total Fees: .;--
277 *
Fees Paid: <;2J'
Issue Date: Balance Due:
2. 7~, (}tj
APPROVAL DATE