HomeMy WebLinkAboutApplicationGARF IFLD G
��icvht "pan r'piFy nCommunity Development Department
108 le Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
Garfield County
TYPE OF CONSTRUCTION
GI New Installation
ONSITE
WASTEWATER
(OWTS)
PERMIT APPLICATION
O Alteration
0 Repair
WASTE TYPE
111Dwelling 1 0 Transient Use
O Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
1
Property Owner: (' Iyl 1a- f 1.1 Phone: ( C70 ) .29:3--49'039
Mailing Address:
7/ 23 /boa"
Contractor: Ot 9N►S NI
Mailing Address: _ 10100 CR ale
Phone: L1970 _ 371- 8WS-
Co 811os-o
Engineer: Phone: (___)
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: _ ra r] nalTi
11 . fi f . . / 7
Assessor's Parcel Number:dr - 134-00- tit. Sub. Lot Block
Building or Service Type: __SINGuE FAA]LI- it S, #Bedrooms:
Distance to Nearest Community Sewer System: *LIMA
Was an effort made to connect to the Community Sewer System: NO
Type of OWTS Septic Tank D Aeration Plant 0 Vault 0 Vault Privy
3 Garbage Grinder
0 Composting Toilet
O Recycling, Potable Use 0 Recycling
O Chemical Toilet
0 Pit Privy
0 incineration Toilet
0 Other
Ground Conditions Depth to 1 Ground water table
Percent Ground Slope
Final Disposal by Absorption trench, Bed or Pit 0 Underground Dispersal
O Evapotranspiration
I 0 Above Ground Dispersal
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type well
Effluent
❑ Spring
0 Stream or Creek 0 Cistern
O Community Water System Name
Will Effluent be discharged directly Into waters of the State?
❑ Yes Na
--J
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. 1
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
V C
(c
Date
as
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
12-3.00
Building
BLDG DIV:
rit
.4
Perk Fe :
IO.DO
Septic Permit:
Sr3�'I'
Total Fees:
23.(512
Issu Date:
Fees Paid:
2-3. av
Balance
if3-l2rvgS �ofz3f�s