HomeMy WebLinkAboutApplicationFIC. Garfield County J
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfi eld-county,com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Jo New Installation
WASTE TYPE
0 Alteration
❑ Repair
❑ Dwelling I 0 Transient Use J 0 Comm./Industrial I 0 Non -Domestic
El Other Describe 1LVt< 4‘L "fvt f...45 "
INVOLVED PARTIES
Property Owner: Gam& lR . 4 C. -&,--r,>0.4-171541 Phone: (
Mailing Address: I+o?. 4. U _' 7' IZ ST./. ►'1T M IO D fr IF -R- GGA F30 7, -
Email Address: S.ie--orvtrf 0.e `- • COP'\, 't-SGla (.0sr A►NG
Contractor: rdat - , Z d b Phone: (17p )6144'-9ieLS-3
Mailing Address:
Email Address:
L4 2- 441-1-g451 - ' lli . +p. , g/6,0 1
ki,kpG,c� � e! cal
Engineer: , S,L . S IAVEai•� "T L C Phone: (q 7p) 9 c74.- X44
Mailing Address: STP _ WS*, DE_ . en?)
Email Address: ("Ge -s i (i' gq Au_ C- AL IAN -1
PROJECT NAME AND LOCATION
Job Address: (7 is ts.
Assessor's Parcel Number 74-1L.,1.1 Z'i-toad Z7 Sub. Ill-? 4- iZANC-4.4- Lot Block
Building or Service Type: V-417,ia#. l 14-F.ODnt Bedrooms: Garbage Disposal _ Distance t
I MO A l '
Nearest Community Sewer System: 4- I 'Kt Lig
Was an effort made to connect to the Community Sewer System: -�
la Septic Tank 0 Aeration Plant 1 0 Vault 0 Vault Privy { ❑ Composting Toilet
I 0 Recycling 0 Pit Privy
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
O Recycling, Potable Use
O Chemical Toilet 0 Other
i
Depth to Ground water tablet iS T
m Absorption trench, Bed or Pit
O Evapotranspiration
0 Incineration Toilet
Percent Ground Slope
0 Underground Dispersal
❑ Wastewater Pond f
CI Above Ground Dispersal
0 Sand Filter
O Other
1i) Well 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 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 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.
Pr • perty Owner Print and Sign('
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I-)%
Perk Fee:
(2
Total Fees:
1:)- 0)
Fees Paid:
j )--- . 6 0
Building Permit
PALO ° q Tit
(---.TO
Septic Permit:
- Lks`9
Issue D te:
3� 3 119--
Balance Due:
BLDG DIV:
l
-', )o 1
` - ' .3�r•2
APPFOVAt DATE
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