HomeMy WebLinkAboutApplicationGarfield County
103 Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
WASTEWATER
TYPE OF CONSTRUCTION
Property Owner: 6 v\r.n h (-31Na
Phone: pin ) �i7C'I - fir, 1
Mailing Address: 5;S Pre- Mcati- A-V
R1 New Installation
•
Alteration
•
Repair
WASTE TYPE
Engineer: 1 -Vo, in Be (I
Phone: ( 9'70 ) 1'i1 ? — 3 I53
Mailing Address: P 0 f )C Rt C
EI Dwelling
0 Transient Use
❑ Comm./Industrial
• Non -Domestic
0 Other Describe
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
A/29- 301 -co nn&
,
Sub. Lot Block
1
61,P
#Bedrooms:
AL) A 1. L t3Lt
'2) Garbage Grinder J J
Sewer System:
connect to the Community
M Di-
Sewer System:
INVOLVED PARTIES
Property Owner: 6 v\r.n h (-31Na
Phone: pin ) �i7C'I - fir, 1
Mailing Address: 5;S Pre- Mcati- A-V
C'. R1c(�, C'1-- Il05()
Contractor: )CL\.p C--rrt`(
Phone: ('cf'7o ) 379 - 578a
Mailing Address: ?,Oi5tr .3h 7- Nto
Ca S-1 le, CO s1(-( `i
Engineer: 1 -Vo, in Be (I
Phone: ( 9'70 ) 1'i1 ? — 3 I53
Mailing Address: P 0 f )C Rt C
ie C n g( 0 SO
PROJECT NAME AND LOCATION
Job Address: Co -3 LI C€2 ati(,,, t t
I✓ (P Cr. SSI ln5o
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
A/29- 301 -co nn&
,
Sub. Lot Block
1
61,P
#Bedrooms:
AL) A 1. L t3Lt
'2) Garbage Grinder J J
Sewer System:
connect to the Community
M Di-
Sewer System:
IV c.
Type of OWTS
: . Septic Tank 1 0 Aeration
Plant
0 Vault 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1" Ground water table
1.2 ' I Percent
Ground
Slope c7-'-I9c a -t feet i, -F,
Final Disposal by
0 Absorption trench, Bed
or Pit 1 0 Underground Dispersal
❑ Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
Other 1 Li F i L,TfJNTtoii
5ysrE-6.4
Water Source & Type
Ii Well
0 Spring
0 Stream or Creek 0 Cistern
❑ Community Water System
Name
Effluent
Will Effluent be discharged
directly into waters of the State? 0 Yes lit No
CERTIFICATION
Applicant acknowledges that the completeness ofthe 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 l 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
OFFICIAL USE ONLY
to -'()-15
Date
Special Conditions:
Per it Fee:
(-3 •D0
Building Permit �
1/ tLT�'E r 31�] �
rX��
BLDG DIV:
Perk Fee:
Septic Permit:
s 9
Total Fees: I Z 3. bo
Issue Date:
Iri-lis
APPROVAL
i
LPgi IDpalfs-
Fees Paid:
ID -3.00
Balance Due:
1/A4/5"
DATE