HomeMy WebLinkAboutApplicationSCANNED
Garfield County
Community Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
VI New Installation
WASTE TYPE
® Dwelling 0 Transient Use
0 Other Describe
ui&
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Comm./Industrial
I 0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: CO u I r r F °, rr+ ; l y Tros4 Phone: (9 7 0) 4) S_1 C, 641
Mailing Address: 7 GO L,1 3 07:14 S4r . Rt' -g19 (0 V 16 S.0
Contractor: i� i ., r - , 5 I n i P...' . Phone: (Q ) fl) kis- 33C/ S
Mailing Address: 1S $0...f C, R, 2 VS eW Cas41 c0 $f 1, kl'3
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: /SOS E! {l RM.,/ 1),-;w Moo Cni5410 Cil R16"1'7
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
R OM O '753 Sub. W. Ef k- Crir , Ran &I Lot 1 Li Block --
On w a #Bedrooms: 3 Garbage Grinder kg
Sewer System:
connect to the Community
) `) m r )e5 S;1
Sewer System: NIA / No
Type of OWTS
X Septic Tank I 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Indneration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1`t Ground water table
I Percent Ground Slope
Final Disposal by
XI Absorption trench, Bed or Pk 1 ❑ Underground Dispersal 1 ❑ Above Ground Dispersal
0 Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
0 Well 0 Spring 0 Stream or Creek Cistern
❑ Community Water System
Name
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.
1 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 cry
d •+�' �� Co u: -TL; t,
1-7/ 2 47I Cl ! S
Date d
OFFICIAL USE ONLY
Special Conditions -
.
Permit Fee: C�
,t/P.S.
Perk Fee: OQ
1 /M.
Total Fees:
AQ93. co
Fees Paid:
4)R9-3. oo
Building Permit
— SAt
Septic Permit:
•E 5811
[slue qa te:
%RI lc
Balance Due:
co
icef.
BLDG DIV: ' E/6/!,c-
APPROVAL DATE
1Paid. ri--?"3 .1 S
J- io3-7 t ;2_ —