HomeMy WebLinkAboutApplicationTIC Garfield County I
Community Development Department
lii 108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
—a, New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
WASTE TYPE
0 Alteration
0 Repair
la Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Pvii-;G:4 )4.,....c... Phone: (
Mailing Address: Ts bi.,4,} - A. &WS (0 gl e0l'
Email Address:
Contractor: EW • L'arS /1I: Phone: ( )
Mailing Address: lot ak- duller a. Nta,1 se CO q/ "1
Email Address: {vies .3Whod•[ovr,
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: r) 91- Mit Ai,:1)r- a. Co ,-,16.,( (
Assessor's Parcel Number: 23g5-611106o1l Sub. Lot 16\ Block
_
Building or Service Type: egsJg-,-ha i #Bedrooms: 3 Garbage Disposal
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
1I, Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 15' Ground water table
Percent Ground Slope
Final Disposal by
0 Absorption trench, Bed or Pit
0 Underground Dispersal ` 0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond 1 0 Sand Filter
❑ Other
0 Well
0 Spring
0 Stream or Creek
0 Cistern
Water Source & Type
0 Community Water System Name
Effluent f Will Effluent be discharged directly into waters of th a State? 0 Yes 0 No
CERTIFICATION
Applicant acknowledges that the completeness of he application is r onditional upon such further
mandatory and additional test and reports as may be required by tho local health department to be
made and furnished by the applicant or by the local health departmi nt for purposed of the evaluation
of the application; and the issuance of the permit is subject to such i . rms and conditions as deemed
necessary to insure compliance with rules and regulations made, int irmation and reports submitted
herewith and required to be submitted by the applicant are or will b,> represented to be true and
correct to the best of my knowledge and belief and are designed to lie relied an by the local
department of health in evaluating the same for purposes of issuing the perrnit applied for herein. 1
further understand that any falsification or misrepresentation may ri sult in the denial of the
application or revocation of any permit granted based upon said am - lication and legal action for perjury
as provided by law.
L. -
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have pl• vided the required 'nformation which is correct and accur ite to the best of my knowledge.
f/7L/7
{
Property Owner Print and Sign
Date
1
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Building Permit
Perk Fee:
Septic Permit:
4 $
BLDG DIV:
M.3123 pod j 1-1, 2 -
Total Fees: ,
I 'Z-? ---
Issue te:
5 011 -1 -
Fees Paid:
17-3
Balance Due:
3k/?O 1'J
DATE