HomeMy WebLinkAboutApplicationCOI
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r=ir0Community Development Department
r_Avov.LD0,
',q*��� 108 8`h Street, Suite 401
.^
)0? D2Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
Garfield County
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
New Installation ; 0 Alteration
WASTE TYPE
Dwelling
0 Transient Use
0 Comm./Industrial
0 Repair
1 ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Ry& Ti// Phone: ( 7O ,) 7H-7- 1--Z.
Mailing Address: / 7
Contractor:
G fe ! 7 GIPS kxrx.0 114))4c cd evior
r Phone: (q" O ) 274"Z30ZZ
Mailing Address: 7-7 cjg 0,0 L,0.1 �,. tj f Co /lid/
Engineer: k+414 r, PfrZ.-•.
Mailing Address: 61 w
GT
Phone: ( 303 ) 70— 7gz3
000 it
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: 2/Men° 2OP1 Sub. Sub.0.122.15.2cirgcLot )'f Block—
Building or Service Type: RtS,. OM #B
1 edrooms: Garbage Grinder
Distance to Nearest Community Sewer System:OTS . tlYrit-eJ
Was an effort made to connect to the Community Sewer System: /kit
Type of OWTS
Rt Septic Tank I. 0 Aeration Plant
0 Vault 0 Vault Privy ❑ Composting Toilet
O Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1" Ground water table 3.510
Percent Ground Slope .41
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
01 well ❑ Spring I 0 Stream or Creek 0 Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
❑ Yes 61 No
CERTIFICAITION
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 quired information which is correct and accurate to the best of my knowledge.
Pro. - •-;y •+'nt and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
PG -op
Perk Fee:
Ei -
Tn*al Fees:
:/2_ 3 . 00 ,
Fees Paid:
j a-3, o)
Building Permit
Ref- E- 3%47
Septic Permit:Issuate:,Balance
SEpr-3$l0—
i�g
(c.
Due:
BLDG DIV:
,�
5Y10,5--
l i
APPROVAL DATE
1 •
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