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Garfield County
1ECEl~ Community Development Department
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
APR 1 ~ 10\G 108 8 111 Street, Suite 401
Glenwood Springs, CO 81601
GARF1ELD v~uN :1: H (970) 945-8212 \~!AUN\1l' OEV1...LOP 1~ B www.garfield-countv.com
~Of.. CONSTRUCTION · ... ----~
l!I New Installation I D Alteration a Repair
WASTE TYPE
·~. • Dwelling I D Transient Use I D Comm./lnd~s!rial I D Non-Domestic -D Other Describe --
INVOLVED PARTIES
Property Owner: A.JAA.JC. y C {J. L I< Ill Phone: (..1.,;70~2-')· ....i.i::~..-.."-.!L..:'1;;._____,
Malling Address: S.'il/O S . Qu EEN SI. L, flLelrvv Co. fro/1 7
Contractor: Phone: ( 97 0 ) 3/ Cf-Of (, I
MaillngAddress: // S, 'P1t1N f e1) lkacC. e'.iit A)EtU C AsfLE Co ~/C'IZ
__ Al{ S co..1lli,$;' SE:p.1:t ''-
Distance to Nearest Community Sewer System: __ -l___.../(,,..)__..M........,1 l ... G~5 __________ _
Was an effort made to connect to the Community Sewer System: ___ IU ...... O..._ ______ _
TypeofOWTS
Ground Conditions
Flnal Disposal by
• Septic Tank I a Aeration Plant 1 c Vault I a Vault Privy I a Compostlna Toilet
a Recydlng, Potable Use a Recydlng I a Pit Privy I a Incineration Toilet
C ChemlcalTollet C Other ______________ _
I Depthtol"Groundwatertable g F&r;f + I PercentGroundstope ~IC"""1_7..;,,,"---
• Absorption trench, Bed or Pit I a Underground Dispersal I a Above Ground Dispersal
C Evapotransplratlon l C Wastewater Pond [ C Sand Fiiter --1
a Other
i
Water Source & Type • Well I a Spring I a Stream or Creek ! a Community Water System Name __ -_--_-_-_-_-_-_~_-_-_-_-_-_-_-:_______ I
c astern
•No =1 Effluent Will Effluent be discha rged directly Into waters of the S~te7 C Yes
'---~------'"----------------~~---
.. ··-.
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 regula t ions 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 purpo ses 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 a ny 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 provided the required information which is correct and accurate to the best of my knowledge.
Spedal Conditions: s / z.~ rtJtJ.. 4 B 1Z-,
Permit Fee: Perk Fee: Total Fees:
IZ.~.DO --1.~. 00
Building Permit Septic Permit: Issue Date:
-·'--' . (o
BLDGDIV: ,d~..a>if-~
APPROVAL
Date
Fees Paid:
2'3. b'o
Balance Due: