HomeMy WebLinkAboutApplicationGarfield County
toz Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
,&t New Installation
•
Alteration
•
Repair
WASTE TYPE
• Comm./Industrial
❑ Non -Domestic
Dwelling T T. Transient Use
0 Other Describe
INVOLVE D PARTIES
Property Owner: en? -/ I a e5. Phone: { 17C Lgt osis- 4039—
Mailing Address: `?/ Pei C Jw i p Co Sd�
Contractor: err n - 5 01 Phone: (97 c3 )
Mailing Address: I P-60 C teiei c7 -14C L C4 V cis -a
'.57-71--a 157
Engineer: /4
Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 0 Sem�G�
>
k• y{
Assessor's Parcel Number: 2,17i- P11 -00-0/S- Sub. firriee e
Building or Service Type: Ie!=[L•
Lot f5 Block
#Bedrooms: 3 Garbage Grinder 0
Distance to Nearest Community Sewer System: Sf M. les
Was an effort made to connect to the Community Sewer System: nD
Type of OWTS Septic Tank
0 Aeration Plant 0 Vault I 0 Vault Privy 0 Composting Toilet
0 Recycling 0 Pit Prlvy D lncIneration Toilet
0 Other
O Recycling, Potable Use
O Chemical Toilet
Ground Conditions
Depth to 1'' Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit
0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond + 0 Sand Filter
0 Other
Water Source & Type 0 Well 0 Spring ; 0 Stream or Creek 1 0 Cistern
Community Water System Name I}); .-; e 4r- ry
Effluent [ Will Effluent be discharged directly Into waters of the State? 0 Yes , . 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.
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.
Property Owner Print and Sig
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
133 at)
Perk Fee:
Total Fees:
123.
Fees Paid:
123 OD
Building Permit
( FA3=I
Se • tic Permit:
�'�>r-43sL
to:1
Issu D te:
�
Balance Due:
BLDG DIV: 140`
L-/4-20 itb
ApPROV,
DATE
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