HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8t Street, Suite 401
51114 Glenwood Springs, CO 81601
(970) 945-8212
0\ www.gariield-county.com
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
[137 -New Installation❑ Alteration 0 Repair
WANE TYPE - - - -
Dwelling 1 ❑Transient Use 0 Comm._/Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Ow r; ryt DT , /OS ori Phone: (9 U ) % 5P)17
Mailing Address: 9) e 2 // &» ▪ ..1 g /62 3
Contractor: -rte Phone: ( )
Mailing Address: 01,1 •Cgv . COP" -
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:_22c_r /) 3 _ �+' gilL2--
Assessor's Parcel Number: 41t3 /7ZD0O Sub. Lot Block
Building or Service Type: 11rrLE C Y #Bedrooms: / Garbage Grinder
Distance to Nearest Community Sewer System: 14 tJ/[.rlWtt)1\/
Was an effort made to connect to the Community Sewer System: !*
Type of OWTS 10'5epticTank
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
0 Aeration Plant
O Recycling, Potable Use
O Chemical Toilet
0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling 0 Pit Privy 0 Incineration Toilet
O Other
Depth to Iu Ground water table U}C mm -i lk/ Percent Ground Slope
I9'orption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration ❑ Wastewater Pond 0 Sand Filter
O Other
finvell 0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes Er No
CERTIFICATION
Applicant acknowledges thit 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 fumished 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 my knowledge.
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Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Feel YJ
Perk Feel
Total Fee3 —
Fees Paid: 2-1-3--
Building Permit
P31,V -14�T
Septic Permit:
L l - 51C
Issue te:
1I2ftTh
Balance Due:
BLDG DIV:
APPROVAL
DATE
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