HomeMy WebLinkAboutApplicationOR 2 8 2416
Garfield County
Community Development Department
108 8"' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garrield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
cit Septic Tank
0 Aeration Plant I 0 Vault
New installation
❑ Alteration
CI Repair
WASTE TYPE
❑ Pit Privy
0 incineration Toilet
IR Dwelling • Transient Use
• Comm./industrial
• Non -Domestic
0 Other Describe
Ground Conditions
Depth to I Ground water table I Percent Ground Slope
Final Disposal by
pi Absorption trench, Bed or Pit
INVOLVED PARTIES
Property Owner: r $ S i 11 Pk- rick
Phone:(/O) TO9V.7139
Mailing Address: 5 ) ;A Dr=,ve Ievt 7i is fit ,s to sObo/
Contractor:n, cL;
Mailing Address: S c� v►n
Phone:( )
Engineer: Phone:
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: L th ciLvui.
Assessor's Parcel Number:,, ,c2 siS 10 J� 0700 Sub. L Gt 2y 0,-A ,t1 A- Lot / D Block
Building or Service Type: Ae5 tke i1i-► u.l #Bedrooms: 1-tl Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: A i' \it u i/u, i4
Type of OWTS
cit Septic Tank
0 Aeration Plant I 0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
❑ Recycling
❑ Pit Privy
0 incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to I Ground water table I Percent Ground Slope
Final Disposal by
pi Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
0 well
❑ Spring
0 Stream or Creek
0 Cistern
Ii Community Water System Name L-cL V..f 4 on.iv I'd /-
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 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.
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.
roperty Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Pemit�F_ee:
I�3 •
Perk Fec
Total Fetes:
Yui-�jJ.
Fees Pajj:
le 43 . CO
Building Permit
like -416+
Septic Permit:
Ser- got
issue
'
te:
al1i
Balance D e:
�4 /6
BLDG DIV: e
APPRO AL DATE
pa.�ens.as, ;sok, 317-gIih