HomeMy WebLinkAboutApplicationINVOLVED PARTIES
Property Owner: sr4 r f I' ■n, s MAI �i�, ,Phone: (Iti ) `f 5
Mailing Address: -70 Z T fv►+� 'V Z- 'b!}C .- (ITV
Email Address: h A leli i 6 1 I4& (0►MGI 11- LGW►
Contractor: 1t. l ('tviPhone: (y1(L) t4'271 10 .1 3
Mailing Address: 3b 70 17D 6visi IQ SS Corm 6tao #k al -mod .�ivtc"fi vi tI
Email Address: o c o vm e i e ct i e t i CGln Ji
Engineer: 11 S€vVI GC, i C. Phone: (MO ) 7D'I Oki +�
Mailing Address: 35 Fi2Vt ir wheel th1of r --0A61 vkc{p (-e 61k2-3
Email Address: Cara - 0 67-1" \o e vi i✓ vIn' i l • c
PROJECT NAME AND LOCATION _
Job Address: -70 2-5 Y
Assessor's Parcel Number: 2,31307 i,‘,.0b0.09 Sub. Firvt/rtld 17tcb4 hA1 Lot Li Block
Building or Service Type: bryvi I1Pi>rlil,,1- i I l #Bedrooms: NSA Garbage Disposal Nb=
Distance to Nearest Community Sewer System: L4 Lr15 (4 V&
Was an effort made to connect to the Community Sewer System:
Type of OWTS
slot # v,iilnIel.e
IX Septic Tank 0 Aeration Plant 0 Vault
❑ Recycling, Potable Use 0 Recycling
❑ Chemical Toilet
0 Vault Privy
0 Composting Toilet
0 Pit Privy
0 Incineration Toilet
0 Other
Ground Conditions
Depth to 15t Ground water table .JCe (q 0/-f C Percent Ground Slope y'1 •
Final Disposal by
O Absorption trench, Bed or Pit I Underground Dispersal
O Evapotranspiration
0 Above Ground Dispersal
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
0 Spring 0 Stream or Creek
Garfield County
Community Development Department
108 8`" Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
0 Alteration
0 Repair
WASTE TYPE
0 Dwelling
0 Transient Use
p Comm./Industrial
0 Non -Domestic
0 Other Describe
IX Well
0 Cistern
O Community Water System Name
;oy
Effluent
Will Effluent be discharged directly into waters of the State?
❑ Yes 13 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. 1
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.
6N -41A/1 19111/Ill 0n 1 [ A 6V117 -
Property Owner Print and Sign AA kM>i lF F f ki'-7141- p V
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
jam—
Perk Fee:
EN%
Total Fees:
113 —
Fees Paid:
I23
Building Permit _
PLC() -LI VS
Septic Permit:
Sti- - Lfl
Issue Date:
LIin�II-
Balance Due:
BLDG DIV: 4/14'®I7
CM
APPROVAL4:42
DATE
PD . 4 o�a –j i/-14-6/51--/ 4