HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
OCT 1 9 Z0�6 108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION _
- 0 New Installation ❑ Alteration
WASTE TYPE
l- it Dwelling 0 Transient Use ] 0 Comm./Industrial
0 Other Describe
I El Repair
0 Non -Domestic
INVOLVED PARTIES 13c/ft Q?[f -as-- 46a_
Property Owner: l c, h , -vela CoU,'lt s / Phone: (9]!} ) 37 c1- //6S`
Mailing Address: po 13o,k /0/7 5-7/t
Contractor: OJ c/r,'r], CdYlSint G/ Phone: ( ) ‘l? 2_ 34Q
Mailing Address: 0 `77C (R /1 4C W ('4IC O /5e)
Engineer: /& 0'3/461 Phone: (3_,D__) 3cjq -
Mailing Address: 33 Four Ofd w'2 r.c) Co. -Ad -hide . Co 5?1,41A 3
PROJECT NAME AND LOCATION
Job Address: 5352\ 62_ 2-,33 S711- I1- Co.
Assessor's Parcel Number: 2‘1)c109,R003-Scl Sub. Lot Block
Building or Service Type: 4rYl--es_ #Bedrooms: 3 Garbage Grinder
Distance to Nearest Community Sewer System: 12,,r G 1
Was an effort made to connect to the Community Sewer System: %V
Type of OWTS
pc Septic Tank ❑ Aeration Plant , ❑ Vault i 0 Vault Privy 0 Composting Toilet
O Recycling, Potable Use 0 Recycling ❑ Pit Privy 1 ❑ Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions Depth to 15' Ground water table r-1. S I Percent Ground Slope A.
Final Disposal by
I.. Absorption trench, Bed or Pit 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type Igt Well 0 Spring I 0 Stream or Creek 0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
❑ Yes R. 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 c rect and accurate to the best of my knowledge.
.4,_"U
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Per it Fee: OD
Perk Fee:
Total FF_eees:
Fees P id• 0
Building Permit
Septi
Issue Date:
Balan e4
A
BLDG DIV: f"141"-NIPI
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A"ROYAL
DATE
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