HomeMy WebLinkAboutApplicationCommunity Development Department
108 8u' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New installation
WASTE TYPE
0 Alteration
0 Repair
Dwelling 0 Transient Use 0 Comm/Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Address:
Phone: (Ct.?D)
Contractor:
Mailing Address:
Po . ery 3L/
Engineer:
Phone: (4?0) 4 tl - 3 ? d G
13-42.-c2%.,6 Cv 91'
Phone: (97o)
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: b 0
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: #Bedrooms: Garbage Grinder
Distance to Nearest Community Sewer System: /v/pi
Was an effort made to connect to the Community Sewer System:
Type of OWTS
i Septic Tank 10 Aeration Plant 1 0 Vault 1 0 Vault Privy 1 0 Composting Toilet
❑ Recyciing, Potable Use
0 Recycling
0 Pit Privy
1 0 Indneration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions Depth to 1" Ground water table
Percent
Ground Slope .
Final Disposal by
Absorption trench, Bed or Pit I 0 Underground Dispersal 1 0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
0 Well
-X(
0 Spring
0 Stream or Creek
0 Cistern
Community Water System
Name 1
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes * 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. 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.
VW"
Property ner Print and Sign)
triiirvLA,
Date Date
3 -
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123.0o
Perk Fee:
EIJC',
Total Fees:
lZ3.cc
Fees Paid:
123•DO
Building Permit
13L -IE- 3C0Sq
Septic Permit:
sErr- 36(Qo
Issue Date:
V 129 k
Balance Due:
f
BLDG DIV: /,/"`-) ii4(
APPROVAL DATE
it,3•oroi vLStic, b q)IT