HomeMy WebLinkAboutApplicationTYP
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212 MAR 3 0 2016
www.earfield-county.com
New Installation
IiVA{STE1RE
Dwelling ] 0 Transient Use 1 0 Comm/Industrial
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Non -Domestic
0 Other Describe
INVOLVED PATIES _s Fx_:
Property Owner: _ _(. _# I-117/( ' Phone: (C g' — t
_
Mailing Address: P. 0 • ea / S/ Lir CD . E16512
Contractor: SAME c. Phone: ( ` 70 )
Mailing Address: -ger-75
Engineer: Phone: ( )
Mailing Address:
T T " NAME MD N:
Job Address: jJ ' r„ t1 y rye e jrig
Assessor's Parcel Number: 2J�)7 2-13C» 765 -sub. F SC _, Lot r / Block
T
Building or Service Type: 5/Q&NTT/ #Bedrooms: 2 Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
kiSeptic Tank 1 ❑ Aeration Plant
0 Vault J 0 Vault Privy [ 0 Composting Toilet
❑ Recycling, Potable Use il 0 Recycling 1
CI Pit Privy 1 0 Incineration Toilet
❑ Chemical Toilet i 0 Other
Ground Conditions
Depth to 1=` Ground water table Percent Ground SIope f ID
Final Disposal by
0 Absorption trench, Sed or Pit I 0 Underground Dispersal 0 Above Ground Dispersal
0 Evapotranspiration
f 0 Wastewater Pond I 0 Sand Filter
❑ Other
Water Source & Type
Well
1 ❑ Spring
0 Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent T Will Effluent be discharged directly into waters of the State? la Yes No
U P'P
Applicant acknowledges that the completeness of the application is conditional upon such fu
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 pr vided the requirinformation which is correct and accurate to the best of my knowledge.
Property Owner
Sign
Date
�� ( ;� , .: ; 0) --
t'2,111,1•1-1-61747-.6)77---
,_ 3st,
-fir _ �1. _ ,e --r
sgsfem izg
_. .. -- - -,
Special Conditions:
Pere- 1, NP Geo
-er
-- eM9ntee,'ed
aired
Permit Fee:
Z 3 . oo
Perk Fee:
?e
0a
E
Total Fees:
$9
ao
Fees Paid:
ee c50
Building Permit
14- r - l
Issue ate:
i 114
10
Balance Due* RE uitp ce
16 °b * r c
BLDG DIV: 'j
.0-01.4.---C
iPt? /6
APPROVAL
DATE
&& .3.343.1.(r)
� . °° 4- . \ ot-lq°t