HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS}
Community Development Department
108 am Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
PERMIT APPLICATION
I TYPE OF CONSTRUCTION
~New Installation D Alteration D Repair 1· WASTE TYPE ·------~ --------J
[Kowelling__ I D Transient Use I 0 Comm./lndustrial _ _.___D_ Non-Domest_ic __ _
D Other Describe -----------------------------
flNVoLVED PARTIES l
Property Owner:--~~,__....:...;;...;....:' =--=-.......__,____..Z--~ ... -""""""t~'""'-""""t.-=----=--=--Phone: ( 91(.> ) i "41 • CAS'e,
Mailing Address: __ '1---L.!.\\...,,u..__(........._, ..... uu.rrb~...-1ca~-2~'J.1.:;.a,,,.3...___,_A...,.)'-'fi-..:tA.J--__,,laa-.r:::u;~_.k.::.....:.:C...___,,/_.12..._ __ _
Contractor: -.-;,"~ g,, ,,r"l.1f / ::D,,)(' Phone: (q-,o f11'1 · G'll.fro
Mailing Address: --~__._.o.___~--..... >'>f..._-ft,....,,., ..... c ,._.\._.(.,._. _ _,A:>~ .... :Tk,..-""'1_.J..____..~""""---'"e, ..... l"""U""-'-1 .... =z.......=---
Engineer:--~o--VJ. -f#U(JR?t£!:S Phone: (OtfD )-O]qr;. Slt'r:S:
MailingAddress: ~ N. \ck1""'D 4e..k :Di'. ~"'2 4SJ:Y:puS lo ~
PROJECT NAME AND LOCATION
Job Address: vl ' \6 l.w at'f L t? ~ -~ Ct'\S..11 i:-G.
I Assessor's Parcel Number: {c:.e.'5 .1£6 · ts ·WY Sub. _________ lot Block __ I
Building or Service Type: ~ert.e.-"f: #Bedrooms: 2-Garbage Grinder %
Distance to Nearest Community Sewer System: __ .... B __ M_J:t..€:" ___ ........ s-1(,.,.....~ ........ -............ •...,) _____ _
Was an effort made to connect to the Community Sewer System: ___ tJ ....... c ... 2 _______ _
TypeofOWTS
Ground Conditions
Final Disposal by
15 ~ptic Tank I D Aeration Plant D Vault D Vault Privy D Composting Toilet
b ecyc!lng, Potable Use C Recycling C Pit Privy C Incineration Toilet
C ChemlcalTollet 0 Other _______________ _
j Depth to 1" Ground water table I I Percent Ground Slope ------
)(Absorption trench, Bed or Pit D Underground Dispersal I a Above Ground Dispersal J
0 Evapotransplration C Wastewater Pond C Sand Fiiter
0 Other------------------------
Water Source & Type ! Well I a Spring D Stream or Creek 1 ~em ________ ---l
I
C Community Water System Name .
Effluent __ --_ -_-_-_-_--~-~+~_w-=_m Effluent be discharged dl~ectly into waters of the State_? _a ve_s --~No
CERTIFICATION
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.
----------------------~-__J
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.
~~ b,hss-I I Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Fees Paid : CC
;:/>I .
Permit Fee: OO
(J /;/, ,
Perk Fee:
Issue Date:
B·tG?·I
Building Permit ea1~ceou00 \l>Q.
BLDGDIV: _~d=.:.._1~--~--.,,,c.-~--------
APPROVAL DATf_I