HomeMy WebLinkAboutApplicationcG Garfield County
Community Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
B New Installation I D Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I D Repair
GJ Dwelling I D Transient Use I D Comm ./lndustrial I D Non-Domestic
D Other Describe
INVOLVED PARTIES _ ,
Property Owner: -C"'"'. ·,_;::s....,,,_U ..... ,.-,:-,,t...,../)......---.(-.]!1".Y,...,,1/-.. ....,..~~· --.-----Phone: ( .zb>) ~/~ -,.,L/v~
Mailing Address: I t/.1 .11/ ~//2 0 A t/~.
Contractor: ____________________ Phone:( ___ ,) _______ _
Mailing Address : _____________________________ _
Engineer: ____________________ Phone:( ___ ) _______ _
Mailing Address=-------------------------------
1--------~~-------~----~-----~~----------~ PROJECT NAME AND LQ.CATION
Job Address: I /J "1 f "-0 r.E-K f.'/ il/~
lot
. __., ~ Block __
Garbage Grinder J_
Assessor's Parcel ~umber : Sub.~k' .5l.IJ6'
Building or Service Type: S / / 7//'t f/711. ty #Bed;ooms: 3
Distance to Nearest Community Sewer System:_----------~-------
Was an effort made to connect to the Community Sewer System:-------------
Type of OWTS Cl\ Septic Tank I D Aeration Plant I D Vault ~ D Vault Privy 'I D Composting Toilet
D Recyding, Potable Use D Recycling j Cl Pit Privy I D Incineration Toilet
D ChemlcalToilet D Other _______________ _
Ground Conditions Depth to 1•• Ground water table I Percent Ground Slope ------
Final Disposal by ·JI Absorption trench, Bed or Pit I D Underground Dispersal I D Above Ground Dispersal -D Evapotranspiration D Wastewater Pond I D Sand Filter
D Other _____ ~--------------------
Water Source & Type '5(. Well I D Spring I D Stream or Creek t a Cistern
D Community Water System Name _________________ _
Effluent Will Effluent be discharged directly into waters of the State? D Yes "'No
CER:rlFICA 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 y knowledge.
hu~4zJ
Property Owner Print and Sign Date
' OFFICIAL USE ONLY
Special Conditions:
Permit Fee: OO ~123
Perk Fee: Fees Paid: ~ /";;J. 3 . 00
Septic Permit: Issue Date:
0'E~4~~
BLDGDIV' ~~
APPROVAL DATE