HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Cómmunity Development frepartment': 108 8th SÛeet, Suite 401
}t|AY 0 1 ?017 Glenwood Springs, CO 8160x
1 : : (9701!145€:212
www.sarfi eld-counw.com
wPE OF COl{STRUCnOil 'tr Alteration
WASTE TYPE
tr Dwelline E Transient Use 8l Comm./lndustrial tr Non-Domestic
EÌother Describe
I]IVOLVED PARNES
PropertyOumer:
Mailing Address:
Phone:
7Z (a ?
Contractor:Phone: (q7'A I
MailinsAddress:
Ennineer:Phone: I )
MailingAddress:
PROIECT ]IAME AI{D LOCANON
Job Address:
Assessor's Parcel Number:lot Block
Buirding orservicery æ, "þgri c*1.4"@t ßarÃ
l\ntoT- eû/,(t ^fßedroomsz /lly'?Garbage c¡røer4/A
Distance to Nearest Community Sewer System:lb/.l
,n¡r'lF;
Was an effort made to connect to the Community Sewer Systeml Yt3
Typeof OWTS Ef scp¡cf¡nf El åcrationPl¡nt tl villt tI YültPrivt tr ComposlÍ¡Toñct
E Recycllng, Potable Use E Recycllng CI P¡t Pr¡vy E lnclneratlon Tollet
E chemical Tollet E other
Ground C.onditiom Dc6 to 1' G¡q¡nd waær tablc 7trFn PcæmGn¡ndSlope I-z 7o
Final Disposal by E nbeorptlon trcndr, Bed or Plt E undcryround Di¡pcrsal El Abour Grcr¡nd Dispcçel
E Evapotranspiration El Wastcwater Pond E Sand Filter
tr ottËr
waterSource &Type ES well El spdæ E StrccmorCreel lI c*tcm
E Community Wat€r Systsm Name t.
Effluent Will Effluent be dlscharged directly into waters of the State? El Yes Ef ¡¡o
i CERT¡FICATION
Applícant acknowledges that the completeness of the application is conditional ypgn such further
niandatory and additi-onal test and reþorts as may be required by the local health de.partment to be
made and'furnished by the applicant ôr by the local health department for pu.rposed.of the evaluation
of the application; and the isöuance of thé permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance with rules ánd regulations made,.information and.reports submitted
herewith'and required tö be submitted by the apÞlicant are or will be represented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatin[ the same for purposes of issuing the. permit applie.d for herein' I
further understand that any falsifiıation 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 acklrowledge that I have read and understand the Not¡ce and Cert¡fication above, as we¡l as,
have provided the requlred information which is correct and accurate to the best of my knowledge"
4l/"- 4,
Property and Sign Date
?D.{7ry7.ût C4 I t+
OFFICIAT USE ONIY
Special Conditions:
Fees Paid:
7T7.602.47.Þo
Total FeesPermit Fee:
l'1,7.ú)
Fee:
lso .oo
Perk
Balancer".,
ú
Seotic Permit:4Þr-¿fþ8x
lssue Date:/+Building Permit
W,P-e,'ü+fr
BUITDING/ PLANNING DIVISION:
DateSign