HomeMy WebLinkAboutApplicationSEP `Z 6 71117
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfleld-countv.com
TAPE OF CONSTRUCTION
}f New Installation
WASTE TYPE
)2I, Dwelling 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
I 0 Comm./Industrial 1 0 Non -Domestic
INVOLVED PARTIES C
Property Owner: e4, 7 v k_ LL 1 r Phone: (Q (Z) 4o (0 to 96 -
Mailing Address: 44 y(:fie
Email Address: 61. red vl 9oaA- i 1 • C
Contractor: OW11 ker: l 4I lel.. 51 Lt�@. � t phone: ((i I2-) 9400 4.4,1,1
4
Mailing Address: 1I6P � +;— 05A Sad MI
Email Address: w y! }Oi –90O 1�/1�{ + : at'�L
Engineer: *414- P€ itl�irl,44- t 1 7 L Phone:L(97-6) 921 - 9 5 to
Mailing Address:Qr ,4 .e- 3 L 1 co�I (rZjJ �M'- 3 L 1 [O �+ [rZj
Email Address: Ikper. t Suprt5 . Viel-
PROJECT NAME AID LOCATION
Job Address: 95 i L r bot'vlre,-3
Assessor's Parcel Number: 393 j4Zeo/o12.-sub.'vito i 'Pays Lot 12., Block
Building or Service Type: re -5 CcC 1.4.Tl# #Bedrooms: 3 Garbage Disposal(Y/N) '(
Distance to Nearest Community Sewer System: VL bit e_ -
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank 0 Aeration Plant I 0 Vault I 0 Vault Privy I ID Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet I 0 Other
Ground Conditions Dept�hto }n Grqund water table f �Perc nt Ground slope
6 d 1N4.+'GY' Apt LNLOG.vi�d $b1 iG�Y
• Absorption trench, Bed or Pit %Undergrou Dispersal 0 Above Ground Dispersal
Final Disposal by
Water Source & Type
Effluent
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
❑ Well 0 Spring 0 Stream or Creek I 0 Cistern
Community Water System Name ylh told 'Perkk.s L70 A
Will Effluent be discharged directly into waters of the State? ❑ Yes
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.
Lrf44N.Regivwn,A4di.bvi
Property Owner Print and Sign
X0(1
Date
OFFICIAL USE ONLY
Special Conditions:
Permit F e:
173. DO
Perk Fee:
Igo • O(2
Total Fees:
2-13. o0
Fees Paid:
21-3. cd
Building Permit
Bigg -41515
Septic Permit:
�- WWI
Issue Date
ID t 1'6119-
Balance Due:
I0/17/9017
7
BUILDING/ PLANNING DIVISION:
,
41
Signed Approval Date
D. * t13•) i* IOW) 61 1.(4
m 19-