HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8'h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-countv.com
illy,15f CONSTRUCTION
Ne , Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
8 Alteration
W E TYPE
Dwelling
0 Other Describe
0 Repair
0 Transient Use -J Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES f Iti:e..1:e_41-Cr.___.
Property Owner:Do ✓r d- 4 a ,cr dcr /vie tip 1 e Phone: (r ) (a / (- a5GC--/
Mailing Address: P, 6/, Ser' G/tF?c,/DG[t r 'l ,., ria C�--/.6121-,
Contractor: _ CC 1OnCif/a Cif/51001d CCP 40-/!41 Phone: ( -7O' ) 6 j �`a'-
�LG
Mailing Address:r __ % f izit d 5e i`+C� 5 Col e C)
Engineer: Phone: ( j
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: '0 M.1 ' /1 -.
A '- r. p
Assessor's Parcel Number:,z ?43004 -sub.+ #IC/1;i� q ,° Lot Block - [
Building or Service Type: 5. /M_ #' cI '1 5 #Bedrooms: .3 Garbage Grinder
_
Distance to Nearest Community Sewer System: ! p7 , /e-,
_ _
Was an effort made to connect to the Community Sewer System: J 0
_,
Type of OWTS
Q Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy 1 0 Composting Toilet
0 Recyding, Potable Use
0 Recycling
1 0 Pit Privy
I 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Dept 'to lit Ground water table f au' 1 Percent Ground Slope 1+ -- i LI ( 1f: 1 P‘
Final Disposal by
u" Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Ot er
Water Source & Type
II
0 Spring
0 Stream or Creek
0 Cistern
Community Water System Name Wt ?f hot ---1- f �yt� x fr r Y / 4 VI t 11-/�
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes VII.;
Aro 5C`C
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.
1 hereby acknowledge that I have re d rn understand the Notice and Certification above as well as
.
have provided the required • tion w ich is correct and accurate to the best of my knowledge.
`Jvu�QluQe „1:07e' �. - ' ' /. s//6
uii'Ll_.
Property Owner Print and Sign
D
OFFICIAL USE ONLY
Special Conditions:
S e ' ‘7 -c Eayml eer'S 7ie -/ 4 9 .r/ ,t9d it /'fei/fCC/ // Co ayerIrD
Permit Fee:
I23.ob
Perk Fee:
EW..
Total Fees:
1 2-3.o0
Fees Paid:
123 -so
Building Permit
R1,1 - -D33
Septic Permit:
s€pi- t{O 4
Issue ate:
s -1(14
Balance Due:
BLDG DIV:
APPROVAL DATE
. 4t126. a)) ✓4 5g rl, 1128117