HomeMy WebLinkAboutApplicationAPit 'L11
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
OF CONSTRUCTION
New Installation
•
Alteration
•
Repair
_RIE
WASTE TYPE
Dwelling • Transient Use
• Comm./Industrial
• Non -Domestic
Other Describe
INVOLVED PARTIES
PropertyOwner: I SVAIN—MaY'Itn /(htAVt Phone: (910 j 4-K -"1$Oc
Mailing Address: 1 0 CMn7 p oo.d a.7 wt r �o g i(oSO
Email Address: kCCkil $eiplai l - Om
Phone: (470 )
Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION —
Job Address: 'Mb Soto-► wtea&. ui7� Mr -c_
02.
Assessor's Parcel Number: a 11 (, 3 Sub. MASI bAtatou .S+. Lot 33 Block
Building or Service Type: heSld #Bedrooms: Li Garbage Disposal
Nearest Community Sewer System: (1/1\ k_
Was an effort made to connect to the Community Sewer System: NO
Distance tl
Type of OWTS
'$. Septic Tank 0 Aeration Plant L ❑ Vault 0 Vault Privy 0 Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet I 0 Other
Ground Conditions
Final Disposal by
Depth to 1st Ground water table
IX Absorption trench, Bed or Pit
Percent Ground Slope
0 Underground Dispersal j 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond [ ❑ Sand Filter
❑ Other
Water Source & Type
Effluent
" Well 0 Spring 1 0 Stream or Creek
Community Water System Name &An (V
Will Effluent be discharged directly into waters of the State? 0 Yes )(No
❑ Cistern
OVJ FS+CtIfeS
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.
Evil �PropertY er Print and►�
Sigrid
n1
AA -7
o;Ia
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123"
Perk Fee:
Isb "
Total Fees:
2/3—
Fees Paid:
z
Building Permit
BLIP .. 41,05c1
Septic Permit:
S� 46I0 0
Issue DIte:
I D l IT--yos
Balance Due:
BUILDING/ PLANNING DIVISION:
(4,, 4417
Signed Approval Date
r
?D. 2-13.00) 11 1ogl--, ►4 I loI 19-