HomeMy WebLinkAboutApplicationGarfield County
D Verlyitunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
mir2aarNori- (970) 945-8212
yS1 ( www.Rarfield-county.com
TIENT
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
El New Installation
0 Alteration
- 0 Repair
WASTE TYPE
El Dwelling 1 0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Kevin & Gretchen Strom Phone: (630567-4042
Mailing Address: 808 Irving Ave, Wheaton 1160187
Email Address: KGIE@sbcglobal.net
Contractor: Doug Hayes Phone: ( 97(1 )61R-6576
Mailing Address: 1002 Blake Ave, Glenwood Springs, Co 81601
Email Address: dhavesconstructionCa7tmai.l.com
Engineer: Deric Walters Phone: ( 970 )945-5252
Mailing Address: 923 Cooper Avenue, Suite 201
Email Address: deric@bu-inc.com
J
PROJECT NAME AND LOCATION
Job Address: 089 Pinion Words l.ajie
Assessor's Parcel Number: 239313306005 Sub. Callicotte Ranch Lot 5 Block
Building or Service Type: single family residence #Bedrooms: 5 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System: N/A
Was an effort made to connect to the Community Sewer System: N/A
Type of OWTS
1aeptic Tank
0 Aeration Plant
0 Vault! 0 Vault Privy 1 Composting Toilet
❑ Recycling, Potable Use
1 0 Recycling 0 Pit Privy
1 0 Incineration Toilet
❑ Chemical Toilet
0 Other
I
Ground Conditions
Depth to 1St Ground water table
Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit
I 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond 0 Sand Filter
❑ Other
~
I7 Well
0 Spring
0 Stream or Creek
0 Cistem
Water Source & Type
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 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.
rty Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
X23 . o v
Perk Fee:
ENG.
Total Fees:
123 • o u
Fees Paid:
123. 00
Building Permit
-�
BL? 141 1
Septic Permit:
5 -- r- ,r
Issue D te: 1
(Dili 111-
Balance Due:
BUILDING/ PLANNING DIVISION:
// ' I /
10/5/20/7
Signed Approval
IV
Date
Pp. 123.00) * I I' Vt 9 I I--