HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
D New Installation ---1-0 Alteration
W~TETYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I Ir' Repair
~~elling I D Transient Use I D Co-mm./lndustrial I D Non -Domestic
D Other Describe
,-------------------------------------------------~~~~------~ INVOLVED PARTIES
Property Owner: f.\i Ta... "i~ Co\.
Mailing Address: £. Q boi<. 'Z.. 6i?
1 Contractor: o., o t r' s= b,, \ \ ~o----w---o--c-¥-----------P-ho_n_e_:_( ______ )~~~~~~~~~~~·----
Malllng Address: --------------------------------
-Engineer: ____________________________________ Phone: ( ___ ) ______ _
Mailing Address :---------------------------------------------------
PROJECT NAME AND LOCATION
Job Address: L../'-1() \ cr:.-.. -J\1\---,J"'""~--------------------{
J
Assessor's Parcel Number: ___________ sub. _______________ lot ___ Block _
Buildi ng or Service Type:-----------#Bedrooms: _"3 ........ ___ Garbage Grinder_
Distance to Nearest Community Sewer System:------------------------
Was an effort made to connect to the Community Sewer System: T ~of\' \-'K (louO
TypeofOWTS
Ground Conditions
' Final Disposal by
~eptic Tank I a Aeration Plant l [J Vault ' 0 Vault Privy I [J Composting Tollet
0 Recycling, Potable Use I 0 Recycling I [J Pit Privy I 0 Incineration Toilet
0 Chemic;i Toilet I 0 Other --
1 Depth to lM Ground water table J Percent Ground Slope -------
0 Absorption trench, Bed or Pit I C:, Underground Dispersal I 0 Above Grou nd Dispersal
1 0 Evapotransplration I 0 Wastewater Pond i 0 Sand Filter
0 Other __________________________________ __
-----t'-=,...._ ___ ..,....,,,,,,.._ ______ ...-::::----------------..,=----------------f
Water Source & Type fa" Well I [J Spring I 0 Stream or Creek
1
0 Cistern
-~-----~~~--~ 0 Community Water System Name _______________________ _
I
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 'liif No ----~~------'----~-~~----------------------·----------~
CERTI F.ICA TION
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 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.
S-7~-l c,
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Total Fees: <:'.J(f
:$ ~).
Fees Paid: co ~?S
Issue Date:
DATE