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l 3 z~mmunity Development Department
MAY 108 am Street, Sui te 401
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
GASF-lti !' .J1U Glenwood Springs, CO 81601
·, .. ~"!'1 \ ~.: I, ·1 . (970) 945-8212
PERMIT APPLICATION
www.garfield-county.com
New Installation D Alteration D Repair
Dwelling D Trans ient Use D Comm./lndustrial
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D Non-Domestic
0 Other Describe ___________________________ _
INVOLVED PARTIES
Property Owner: Dhl .t. lr-'-1' .l LlrPin Phone: ( ~70 ' ~(~. • £!1"3
Mailing Address: 1'3 1r~aiJL c.(U..£.\!.... b9-, ~~SP~$ ~ 'O l<t:>o \
Contractor: ~(...C. 'jT B&ri.u... za trtA2..U.. 6 ~'M-, Phone: (97" ) 9:1la:-.11 f ,---
I Mailing Address:
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I Engineer: IJ fir Phone: ( )
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Mailing Address:
PROJECT NAME AND LOCATION '-,
Job Address: T•'>· h.
Assessor's Parcel Number: 2Jt;J1S+o2.ciZ .. S Sub.kk.Dui /VITrJ . /Lyt!f-Lot Z? Block ---·-
Building or Service Type: ~. f . 'D. #Bedrooms: j Garbage Gri nder _I
Distance to Nearest Community Sewer System: f"1 IL-f..S
Was an effort made to connect to the Community Sewer System: J./6
TypeofOWTS OI Septic Tank l a Aeration Plant l a Vault ! a Vault Privy I a Composting Toil et
C Recycling, Potable Use C Recydlng ! C Pit Privy . , 0 lndneratlon Toilet
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I C Chemical Toilet a other .
Ground Conditions l Depth to 1" Ground water table j Percent Ground Slope
, Final Disposal by JQ. Absorption trench, Bed o r Pit I a Underaroun~ Dispersal I c Above Ground Dispersal
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Water Source & Type
Effluent
a Evapotransplratlon _J a Waste,.,ater Pond I a Sand Filter.if' ~(S°l.BL,..C/
a Other
JI Well • C Ostern I a Spring I a Stream or Creek
' 0 Community Water System Name t:dl~ M n.:f ~
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Will Effluent be discharged directly Into waters of the State? C Yes No
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CERTIFICATION
Applicant ac nowledges 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
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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 I 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.
PrJ!f.9t1.;~d Sign~ UtcilO Datei I
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
l'Z.~.00
Perk Fee :
150.00
Fees Paid: 1 "2. i 7.00
Building Permit Balance Due: