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HomeMy WebLinkAboutApplicationGarfield County APR 0 5 2017 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 TYPE OF CONSTRUCTION Property Owner: Mtn ex.lic(-1 $ Q ck. ROSSOtA Phone:. )a- -436,0 Mailing Address: kS % 2 MOU.Ni-a,., c 17. Akrc Contractor: Q. VC Phone: ( ) ►:f New Installation Engineer: A 1 i CSiCQ. ,- Cavi°. 3SCcivroj Phone: (q1O ) 30q -52..S9 • Alteration • Repair WASTE TYPE Building or Service Type: ESiC le.ir #Bedrooms: 3 Garbage Grinder Distance to Nearest Community Sewer System: tDit Was an effort made to connect to the Community Sewer System: .1A Type of OWTS X Septic Tank I 0 Aeration Plant Dwelling • Transient Use ❑ Recycling, Potable Use • Comm/Industrial 0 Pit Privy • Non -Domestic • Other Describe 0 Other Ground Conditions Depth to ft Ground water table Percent Ground Slope Final Disposal by 0 Absorption trench, Bed or Pit 1 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond INVOLVED PARTIES Property Owner: Mtn ex.lic(-1 $ Q ck. ROSSOtA Phone:. )a- -436,0 Mailing Address: kS % 2 MOU.Ni-a,., c 17. Akrc Contractor: Q. VC Phone: ( ) Mailing Address: Engineer: A 1 i CSiCQ. ,- Cavi°. 3SCcivroj Phone: (q1O ) 30q -52..S9 Mailing Address: PROJECT NAME AND LOCATION Job Address: 1-16D Dd -S a rc.4ei Assessor's Parcel Number:�,��](nf O- Sub. (QtectnCd`(NQSc. Lot 4 Block --- Building or Service Type: ESiC le.ir #Bedrooms: 3 Garbage Grinder Distance to Nearest Community Sewer System: tDit Was an effort made to connect to the Community Sewer System: .1A Type of OWTS X Septic Tank I 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 1 0 Incineration Toilet I ❑ Chemical Toilet 0 Other Ground Conditions Depth to ft Ground water table Percent Ground Slope Final Disposal by 0 Absorption trench, Bed or Pit 1 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter ❑ Other Water Source & Type 0 Well 0 Spring 0 Stream or Creek 0 Cistern gCommunity Water System Name j,k15.tilltAf NSCn COMM. wow- o -Effluent Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 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. 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. \Q5200x 55CLK Property Owner Print and Sign 4-4-1'7 Date OFFICIAL USE ONLY Special Conditions: Atm/ ,0* -t ilio hod 64.41folovv+S oi4 1n-f41191iz4 (JA4rC.Yh,GN} Will rel VA' X. IArrixei °zph'c sy 9t.ewr . pc/mit Fee:�� b -is %. Perk Fee: � V1P e-' Total Fees: 0 p 4 QS. Fees Paid: ©O i Building Permit blar_1-\55 Septic it: E SL\(Q5 Q Issue Dte: (O •?A 9 Balance Due , BLDG DIV: ..t.wii%. j a i 17-617 APPROVAL DATE (613s5 zQZ