HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8'h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
TYPE OF CONSTRUCTION
▪ New Installation
WASTE TYPE
® Dwelling ❑ Transient Use B Comm./Industrial
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Alteration
❑ Repair
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Rv aprrr FF
Phone: ( b) tt (2, G co__+creiLl
Mailing Address:44z 5 3 5 wv L'7t -4, o Ste, az- 945 - S704
Contractor: Phone:
Mailing Address:
Engineer:
Mailing Address:
PROJECT NAME AND LOCATION
Phone:(
Job Address: ,Idv 5 14-1 &I-w..,coy e atzaha ani6-124141-1.-fir-s-1-0-3 r r A7
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: j-i-Dtyt .. ((Bedrooms: 2. Garbage Grinder No
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
lir Septic Tank �i ❑ Aeration Plant 0 Vault 0 Vault Privy
❑ Recycling, Potable Use in Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other
O Composting Toilet
Ground Conditions
Depth to 1" Ground water table
Final Disposal by
Percent Ground Slope
® Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond
0 Sand Filter
0 Other
Water Source & Type ® Well
0 Spring 0 Stream or Creek
0 Cistern
0 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.
tc.Orel 2. k-kFb•FF-
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Fee:
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Perk Fee:
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Total Fees:
#7/70C" al)
Fees Paid:
3S. DD
Building Permit
Septic Permit:
r `17•S
Iss erDat�,:
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Balance Due:
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DATE
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