HomeMy WebLinkAboutApplicationGarfield County 1
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
rrinl+�.-....field-c,
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation ❑ Alteration f 0 Repair
WASTE TYPE
Dwelling 0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner:151 `= t 5 0:1:PA-57
Phone: (q'70 ) 3'7q ,e? ‘,Z-4
Mailing Address:
Email Address:./ �14' L k)it) g 2?
Contractor: A( cPhone: ( )
Mailing Address:
Email Address:
Engineer: A/7/{ Phone: j )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 3 '7> (o iw. i;
Assessor's Parcel Number:Z315 /.8.3 C;70015 Sub. L.-11-2.-"/ L14I0 ii Lot 3 Block
Building or Service Type: f CS • N!`IXt- #Bedrooms: 2 -
Distance to Nearest Community Sewer System: h(o ,7 ' i --!'
Was an effort made to connect to the Community Sewer System: No
Type of OWTS
Garbage Disposal /
\Septic Tank 0 Aeration Plant ! 0 Vault 0 Vault Privy
❑ Recycling, Potable Use 0 Recycling I 0 Pit Privy
❑ Chemical Toilet I 0 Other
O Composting Toilet
0 Incineration Toilet
Ground Conditions
Depth to 1g Ground water table
Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
O Well 0 Spring 0 Stream or Creek
'Community Water System Name
0 Cistern
2-Y b i f1 AA -,-3s A
Effluent
will Eilluerabe•.I1SCrSai„L'LI directly into waters of the State? 12. Yes ,No
CERTIFICATION ;r :;u :i..•..., .
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 an 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.
—17 l
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I23•oa
Perk Fee:
Ise tip
Septic Permit:
Total Fees:
2/3.00
Issu- Dat
Fees Paid:
123 • oo 11_
BLDG DIV:., _
APPROVAL
pia
Balance Due:
P.m
4/z/oo17
1).D. (y3 .our 144P-56-+;tI 1 y) 1'g --
'PD. ISS.?, CC, (130j19 -
DATE