HomeMy WebLinkAboutApplicationcG Garfield County
Community Development Department
108 gth Street, Suite 401
Glenwood Springs, CO 81601
(970} 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
QI New Installation I D Alteration
'WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I D Repair
l2l Dwelling I D Transient Use I D Comm./lndustrial I D Non -Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: i.v~1 5 ~ 1°CaVltCI Ar'flol"'-Phone: ( '>ZU ) :l fol -Bfnl/ D
I
Malling Address: {o.q& P,,·15tl, (CJ~ ~q~ S1 I:! I CQ &lfo 6 i..
Contractor: ~l ! !6 l Cll"'baa ~~~"'ll'"' b(/l'\ Phone: ( q 7 o ) q '-l 2• -&,:Zc). '2
Mailing Address : (~!.ri~ sk'.!:lil 1 t::\~~f ~~ S:1 l \-,CQ ~I ~£! ;;t,
Engineer: F""''' .l-k'.',, ""II' Phone: ( 970 ) :l!e:l-:;.;ia~
Mailing Address: '>2b al tAJi\ ~~ B-:20~ ( tlv' t,IJhJ4 l, , (b ,. £d ~ ;;?3
PROJECT NAME AND LOCATION
Job Address: <:;. ~ M 1 ... ,l..,_,s f .dr..k<:.
Assessor's Parcel Number: l!!l]'.jllS'~c;,i 030 Sub. Lot ,:i'C) Block --
Building or Service Type: #Bedrooms: :i Garbage Grinder_
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type ofOWTS :Bl Septic Tank I a Aeration Plant I a Vault I a Vault Privy I a Composting Toilet
0 Recycling, Potable Use a Recycling I a Pit Privy I a lndneratlon Toilet
D Chemical Toilet 0 Other
Ground Conditions Depth to 1" Ground water table I Percent Ground Slope
Final Disposal by IJ Absorption trench, Bed or Pit j IJ Underground Dispersal j IJ Above Ground Dispersal
0 Evapotransplratlon a Wastewater Pond I a Sand Filter
IJ Other
Water Source & Type ~Weil I a Spring j 0 Stream or Creek I D Ostern
D Community Water System Name
Effluent Will Effluent be discharged directly Into waters of the State? IJ Yes 0 No
CERTIFiCATIQN ,,.
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
~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.
l..;s Amelie ~~J <.-"1 -l 1i
Property Owner Print and~ Date
OFFICIAL USE ONLY
Special Conditions:
Fees Paid :
:1>2 ao l mltfee: OO
J '3. 00 Total Fees:
~;:>?
Issue Date: Balance Ouelx>
~ .
z~s-z~lf>
DATE