HomeMy WebLinkAboutApplicationGarfield County 1
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
B New Installation
WASTE TYPE
lir Dwelling
0 Other Describe
but.' IthiAq
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
B Alteration
0 Transient Use
tar Repair
® Comm./Industrial I 0 Non -Domestic
INVOLVED PARTIES
Property Owner: Ma Z. t} . rU4 (‘,1 •
Phone:
Mailing Address:
Contractor: 'I , . A, . 1 .. ., .
Phone:
( c1'76, )- 41St - b o'')/
Mailing Address: `P. (}, 'Rex 2 13 Or-ft-Lao,�A. in 9/4a.1�
Engineer: Phone:
(
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: / O
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
Z 39 it Z..0 3lSub. . Lot Block
,v.„t , i #Bedrooms: J Garbage Grinder a
Sewer System:
connect to the Community
Sewer
Plant
System:
0 Vault
❑
Privy
Vault Privy ❑ Composting Toilet
Type of OWTS
5ep71ank 1 ❑ Aeration
0 Recycling, Potable Use-'
0 Recycling 0 Pit
❑ Incineration Toilet
0 Chemical Toilet
❑ Other
Ground Conditions
Depth to 1" Ground water table
Percent
Ground Slope
Final Disposal by
Al Absorption trench, Bed or Pit
1 0 Underground Dispersal 0 Above Ground Dispersal
0 Evapotranspiration
0 Wastewater Pond
❑ Sand Filter
❑ Other
Water Source & Type
Well 0 Spring ❑ Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes Iii 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 1 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.
44-
,Prppt=rty Owner Print and Sign
Pe -
Date
OFFICIAL USE ONLY
Special Conditions:
5 Fr SPA -Pt -ex i9
) c4( R1-414.14
��.r4,r
Permit Fee:
3-s• oo
Perk Fee:
0 •OD
Total Fees:
225- by
Fees Paid:
22S.bo
Building Permit
p
Septic Permit:
11•_391(
Issue Date:
Balance Due:
BLDG DIV: r
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APPRO DATE
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