HomeMy WebLinkAboutApplicationCommunity Development Department
108 8th Street, Suite 401.
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation 0 Alteration
❑ Repair
WASTE TYPE
Dwelling j 0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIESyg
Property Owner: IC DP-rtSrMilPhone: (9 )-b30 IDLig g
J�
Mailing Address: Ib1g LAADII1iU-_t 1ir. GLe/IAA/05a NC) DIW
J
Contractor: Phone: ( )
Mailing Address:
Engineer: ifFITIrt'r%
r! Frrr t / Phone: (L----024=2--g->-----
)Mailing
Mailing Address: 3 II
I e1/ ' 0
PROJECT NAME A D LOCATION •
Job Address: LY/ � Is
Assessor's Parcel Number: 2 L1.04'Of/ Sub. WM 1 k ✓✓ Lot If Block
Building or Service Type: [.�hi #Bedrooms: r Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy I ❑ Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
0 Chemical Toilet
0 Other
Ground Conditions
Depth to 1" Ground water table Percent Ground Slope
Final Disposal by
9( Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
❑ Sand Filter
Other
Water Source & Type
�❑l
10.Well 0 Spring
`Community
0 Stream or Creek
0 Cistern
❑ Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 No
+GERif1FfGAf101 ;
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 acknowledmtba9 have read and understand the Notice and Certification above, as well as,
have provided tfine requir-cfn a I n which is correct and accurate to the best of my knowledge.
Property r Prin n ' ign
X/41"7
Date
OFFICIAI.:USE ONLY - - -
Special Conditions:
Permit F e:
P3-00
Perk Fee:
Total Fees:
1x3.00
Fees Paid:
Building Permit
Rie- LIll1-3
Septic Permit:
sal---ir2
Issue Da
1 Up
Balance D e:2
BLDG DIV: A • OigA
APPROVAL DATE