HomeMy WebLinkAboutApplicationGarfield County
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108 8th Street, Suite 401
Community Development Department
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
ig New Installation
WASTE TYPE
Dwelling
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I 0 Alteration
0 Transient Use
0 Repair
0 Comm./Industrial 0 Non -Domestic
%Other Describe
INVOLVED PARTIES
Prooertv Owner:
ER.
Phone: (l 7X71
Mailing Address: 1l) 2 t t)?e_W G,Bp a_ (t S Co 3% to b
Contractor: P '•_ .t - _ li, Phone: (____)
Mailing Address: 4itA.AF' I 1 "_ [1 Y' r. s - + .
I
Engineer: /U Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: rre D / rvie v it n1-71) PaArl9 g c.,•l 3 i
Assessor's Parcel Number: 9i 67 173 nLO3hub. Lot Blodc
Building or Service Type: Oust77j && S BBedrooms: Garbage Grinder VP'
Distance to Nearest Community Sewer System: V o i Aiic1 A%t r
Was an effort made to connect to the Community Sewer System: +i/A
Type of OWES
0 SepticTank 10 Aeration Plant
l] Vault
0 Vault Privy
I 0 Composting Toilet
0 Recyding, Potable Use
0 Recycling
0 Pit Privy
nd
0 I neration Toilet
0 Chemical Toilet
0 Other
-- „ -
Depth1'� T'I
Ground Conditionsto Ground water table 17/00
I Percent Ground Slope
Final D/sposal by
j Anion trench. Bad or Pit
0 Underground Dispersal 1 0 Awa Groead Dispersal
I
0 Evapotranspiration
0 wastewater Pond
0 Sand Filter
0 Other
Water Source & Type
0 Wial
0 spring
0 sty or crsa,
0 cistom
0 Community water System Name
Effluent
Wal 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.
I hereby adcnowledge 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.
if2 &i 4.-4)/.2 fZ
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
special Conditions:
Permit Fee:
?-3. 66
Perk Fee:
151).17o
Total Fees:
/13. co
Fees Pall:
21-3.6D
Build! Permit
r 3960
Septic Permit
1W -39b1
Issue Datil: :
lop( 3i 1 Ie
Balance Due:
56
BLDG DIV:
"
1'"` /e/0/4j'
APPROVAL
DATE