HomeMy WebLinkAboutApplicationFc- Garfield County
Community Development Department
108 8t' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
Dwelling ❑ Transient Use
Other Describe
INVOLVED PAR�
Property Owner:
Mailing Address:
Email Address:
Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
T ❑ Alteration
❑ Comm./Industrial
Phone:
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I& GTA . (_b�^
l�� Phone: f
❑ Repair
Phone: (_�
❑ Non -Domestic
WIN
PROJECT NAME AND LOCATION, _ _ t —
Job Address: Lam; :J1L��1 1.t A
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: #Bedrooms: q._ 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 ❑ Aeration Plant ' ❑ Vault 1 ❑ Vault Privy Composting Toilet
❑ Recycling, Potable Use❑ Recycling f [3Pit Privy ❑ Incineration Toilet
[3Chemical Toilet I ❑ Other
Ground Conditions Depth to 1°t Ground water table Percent Ground Slope
Final Disposal by Absorption trench, Bed or Pit ❑ Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration ❑ Wastewater Pond ❑ Sand Filter
❑ Other
Water Source & Type 13 Well Spring ❑ Stream or Creek Cistern
1
❑ Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes No
I
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.
XZ 21/Z `2
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees:
Fees Paid:
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00
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Building Permit
Septic Permit:
Issue Date:
Balance Due,
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BUILDING/ PLANNING DIVISION:
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Signed Approval
Date
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