HomeMy WebLinkAboutApplicationSEP 2 5 701
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation
Alteration
0 Repair
WASTE TYPE
Dwelling
0 Transient Use
1 0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES Al
r
Property Owner: illifil,ti � itri1i{��LJW��'f Phone (* 1 .� w
Mailing Address: ! 7 6 j U Cars Of)f'jc 0 g/C2 3
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(tit
Email Address: llir�J k V' D IU 0 i7& t
Contractor: tr Phone: (97 0) ).57 75,9
Mailing Address: r-cr. eote Cir --4 a. 11/e -
Email Address: S a 04e ec i Ct ve
Engineer:
Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
1'(p Ur KW jS—
Assessor's Parcel
i
Number: Sub. Lot Block
r .,
Building or Service Type: VfS' ek� t _ #Bedrooms: Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground Slope
Final Disposal by
XAbsorption trench, Bed or Pit
I 0 Underground Dispersal
0 Above Ground Dispersal
0 Evapotranspiration
0 Wastewater Pond
0 Sand Filter
0 Other
X WeII
0 Spring
0 Stream or Creek
0 Cistern
Water Source & Type
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes A No
Effluent
_ r -0101k( Shhy
UOI
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. 1
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 a d un to:. Notice and Certification above as well as
have provided the required informatio and curate to the best of my knowledge.
4:f/1f d „d
1 14/ ke I0 /660
Property Owner Print and Sign
OFFICIAL USE ONLY
77s-)
Date
Special Conditions:
QA by i w1occ,{,'o pr ibv '>b bAckFUI of' now tank.
Permit Fee:
Building Permit
Perk Fee:
Septic Permit:
BUILDING/ PLANNING DIVISION:
Total Fees:
fc.
Issue Date
Signed Approval
Fees Paid:
Balance Due:0
/Z,f9oJ7
Date