HomeMy WebLinkAboutApplicationaitir-- Pee m r-�- 35o
Garfield County
Community Development Department
108 8`h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
8 New Installation Alteration
WASTE TYPE
Dwelling 0 Transient Use
0 Other Describe
0 Repair
IR Comm./Industrial ❑ Non -Domestic
INVOLVED PARTIES c. fLyy . LL L (°
Property Owner: .3-011,4,, a i c ii Il cr t lax* Ph6te: ( 9 ) 37 9 - 6-'6, (tr.c)
Mailing Address: `d>4. Cc -1,1. t.._ Creel/. D r- C-�(-.L S(L> 51(eO 1
vO*iri '
Contractor: A #n e Lk., C--0„ \ 1- Phone: (970) I cI - 6. y (e h
Mailing Address: PO Sok ctcrc , r N eLo Ca -1-1-e,, (( `d I (r. `--i 7
Engineer: A P 6e43 -1-e r Phone: (Q'-70)
Mailing Address: 50-A0 C R. }54 , Las , C [) co, (0c
PROJECT NAME AND LOCATION
Job Address: 101, n 3"3 N -Cw Ccs+ 1 n.—
Assessor's Parcel Numbers 4 --' Sub. 17a �ti,, Lot r /p Block/ a -
Building or Service Type: (4.--.;) c t} 4/1-4 I a #Bedrooms: 4 Garbage Grinder _
Distance to Nearest Community Sewer System: ID i' Lys h11 tis
Was an effort made to connect to the Community Sewer System: 11
Type of OWTS
by -Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
�}
0 Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to In Ground water table Percent Ground Slope
Final Disposal by
El Absorption trench, Bed or Pit 0 Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type Well 0 Spring 0 Stream or Creek N. Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes No
Effluent
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 a d accurate to the best of my knowledge.
12-V- d t'C GCS
operty Owner rant and Si
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
46- . up
Perk Fee:
Total Fees:
•Db.
Fees Paid:
ilS.6b
Building Permit
BUM-- cc -i - 1,'
Septic Permit:
- "IP' - ' IC- 3112 I
Is ue
Fri
i S
Balance Du •
BLDG DIV: ��1 `` /Ci -/ ? hf
APPR • DATE
. 1
• I •00, SD -13/ Ito Iite1iS