HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION -
ONSITE WASTEWATER
TREATMENT SYSTEM
{OWTS)
PERMIT APPLICATION
i'J New Installation I D Alteration I a Repair
'WASTE TYPE
jlJ Dwelling I a Transient Use I a Comm ./lndustrial I a Non-Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: C. Phone: ( ___ ...__ __ lll!:...:......_......:...:.=~--<
Mailing Address: )"]~ A-ventlj lt uew to.)t\t-, Cp ~I lo~J
Contractor: C. Phone: (91o ) (p ~(,p
Malling Address: JJ'f A-ye.rlj t+ tJM Ca~C,1 CD ~~7
PROJECT NAME AND LOCATION
Job Address: Of+ \ C
Assessor's Parcel Number:.2 l:z4o52o~007 Su b.'3_.'-'--6_...._ _____ Lot rJ Block
Building or Service Type: SVf¥1\e._fa.µ\l~ \-\o{)\.Q.. #Bedrooms: 3 Garbage Grinderµ/
Distance to Nearest Community Sewer System:-------------------
Was an effort made to connect to the Community Sewer System:--------------
TypeofOWTS Septic Tank 0 Aeration Plant C Vault 0 Vault Privy 0 Composting Toilet
0 Recydlng, Potable Use 0 Recydlng C Pit Privy 0 Incineration Toilet
0 Chemical Toilet
C O~er _________________ _
Ground Conditions Depth to 1 Ground water table Percent Ground Slope ------
Final Disposal by D Absorption trench, Bed or Pit D Underground Dispersal 0 Above Ground Dispersal
C Evapotransplratlon 0 Wastewater Pond 0 Sand Filter
0 O~er _____________________________ _
Water Source & Type Well D Spring D Stream or Creek C Cistern
C Community Water System Name __________________ _
1--------~--1----~· Wiii Effluent be discharged directly Into waters of the State? 0 Yes No Effluent
CERTIFICATION
Applicant ac nowledges t at the completeness o the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
I
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
·1 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
I 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
I
' 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
which is correct and accurate to the best of my knowledge.
10 -L\-l~
l\ ner Print and Sign f>et~t\
Date
OF.f.l(;IAL l)SE ON~Y
Spedal Conditions:
Total Fees:
a..0>
Fees Paid:
'V '3 .oo Perk Fee:
&"b.Q)
Permit Fee:
,~.Ob
Balance Due: Septic Permit: s ..-1.1"1~
Issue Date:
. \ (.Q
DATE