HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
www .garfield~countv.com
OF CONSTRUCTION ---New Installation --[ 0 Alteration D Repa_!!
W~ETYPE
BDWellin~ l 0 Trans!ent Use -__ j b -C ~mm./lndu~riat ___ D Non-Domestic
------4
0 Other Describe ---------------------------~ ------------~-----
[INVOLVED PARTIES
Property owner: DAiie. 01ASS etJDcf2.= Pho ~ 9'il 7~i'a
1 Mailing Address: l/811:_ _Couw-:y P MO 1 ~'d
' Contractor: S A WI .e.... Phone:{.._ _________ J •
Engineer: ___________________ Phone:{.__ _ __.. ______ _
Mailing Address: ____________________________ _
PROJECT NAME AND LOCATION
Job Address: TB D L oi *s= Home. Sl eAD E s~ &Me STeA P. B."Q-c;..1;mw~~. (o
Assessor's Parcel Number:~ I 81Jfu2o@S'Sub. Htr"1e STeAO _silot f'" Block __ j
Building or Service Type: 5, "SJ .e. fM 1 l..f #Bedrooms: if Garbage Grinder B.o
1
Distance to Nearest Community Sewer System: __ 1_D_01 ___ 1~L .... es _______________ _
Was an effort made to connect to the Community Sewer System: __ A/~O~---------
TypeofOWTS I ii ~ptlc Ta~~l D ~e~tlon Pla~t J ': ~ault I D ~a~I~ Prl:_ 1 D Composting Tollet
; a Recydlng, Potable Use r D Recydlng I D Pit Privy T D lndneratlon Toilet
i I I 0 ChemlcalTollet j 0 Other ______________ _
Ground Conditions Depth to 1111 Ground water table r .z.,, V "\ ;: I I Percent Ground Slope -'-~-~----
' Final Disposal by ¥ Absorption trench, Bed or Pit j D Underground Dispersal ' D Above Ground Dispersal
I [J Evapotransplratfon I D Wastewater Pond a Sand Fiiter
[J Other~----------------------
Wat er Source & Type ~" J O Sprlng D Stream or Creek]" D Ciste rn
[J Community Water System Name _______________ _
-----Effluent • Will Effluent be discharged directly Into waters of the State? D Yes No ~
CERTIFICATION
r-Applicant acknowledges that the co mpleteneS'SOf 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 ___ _,
I hereby acknowledge that I have read and understand the Notlce and Certification above as well as
have provided the required information which is co ccurate to the best of my knowledge.
7 -/<tJ -1oJ(a
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Pennltfee: 0 12 ~ Perk Fee: (!$'
ISD.
Total Fees:
.-Z. 7 '3 . eJO
Fees Paid:
Building Permit Septic Pennlt: Issue Date:
-4 ~-
BLDG DIV: _ ___:..d _ _.,,,.,~~:;;....;:=---tf-....,-:-,.L~-~------------
DAT£ I APPROVAL