HomeMy WebLinkAboutApplicationJUL211011
GA DV1 GOU PtANI
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
X Dwelling
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
1 0 Repair
0 Transient Use
_ 0 Comm./Industrial
0 Non -Do estic
INVOLVED PARTIES
Property Owner: Lka01 NLIt.kS G'L
Mailing Address: `'{'Z -S. K�w^
(aCO
Email Address: CIA -Mk. (t D(eS
Contractor: 3G Cork5}futc
Mailing Address: PQ 1.54k -24(c.,
Email Address: fA«r°__ (j_ Ce»
Engineer:1
ait[,raoc� S ri�.ey S r Co .'(bol
--phone: (g -TO )
ailing Address:
t -
'Lt,i lam -
Email Address: S +Lt.d ;Owt
-3T1--34/v5-
+(e, C O (V/
�rrl3tfj . 01-,
Phone: (9 ) 366 �6�0
6,44
PROJECT NAME AND LOCATION
Df &GA, co e bot
i+'A4i (, truest
Job Address: 39 O log[ 1N t' of SP(4 c -(e iab' of Sp
L -t' .91601
Assessor's Parcel Number: Sub. Lot J Block
Building or Service Type: 51�9 f� a (I edrooms: Z arbage Disposal _ Distance t
Nearest Community Sewer System: 'a k xiec.d.tr-35
Was an effort made to connect to the C mmunity Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
ept€c Tank
O Re . cling, P
O Chem .,ITo
0 Aeration Plant
table Use
let
cstl Ue to0ccF d'o ac. -
❑ Vault
0 Recycling
0 Vault Privy
0 Pit Privy
0 Composting Toilet
0 Incineration Toilet
0 Other
Depth to 1st
nd water table
O Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal
r 0 Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
O Other
O Well 0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ 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.
&ma /tlr c -kr cif
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:123..�113
Perk Fee: ISb
Total Fees:
Fees Paid:2,1*� ......m•
Building
Building Permit
Septic Permit:
Issue Date:
Balance Due:
BUILDING/ PLANNING DIVISION:
t
f c
,\f/)
Signed Approval
Date
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