HomeMy WebLinkAbout1.35 OWTS Applicationt
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GARflEL D G "''
1MM\'M7Y.., -
Garfield Co1111ty
Community Development Department
108 9th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Iii New In stallation I Iii Alteration I D Rep air
WASTE TYPE
JiJ Dwe lling I D Tran sie nt Use I ~ Comm./lndustrial 1 D Non-Domest ic
D Other Des cribe
INVOLVED PARTIES
Property Owner: _-:=C:;.;lh:...;..;.....:.l..:..+---f="1~0tt.uz;;.~U~• ..:l;..:.;N::.it._ ____ ~--Phone: ( tt7o ) . .--,:/.._'f._,_.,_-~~_,__~
Mailing Address : " a. R. 1 1 :3 og,c.Q
I Contractor: OczttNr.S ~rJ Phone: (..i?D -.3-"A -8 lo).$'" -I Mailing Address:_
----
f()OO (.R. d)t/-8 ~i=L\, <o 81tpSo
-Engineer: Phone: ( )
Mailing Address:
-PROJECT NAME AND LOCATION
Job Address: -r.Rn r .R ~JI Ji J ,.-1 I • /1 A .<! J.. ,_..,. ~In_ Yini'17
Assessor's Parcel Number: dl1q-. J'3'J -OO -l>tle Sub. lot Block --
Building or Service Type: ~.Nutt Mr-1'-t" l!.Es . #Bedrooms: 3 Garbage Grinder 4.
Distance to Nearest Community Sewer System: ~m·~
Was an effort made to connect to the Community Sewer System: t::J..O
TypeofOWTS JI( Septic Tank j Cl Aeration Plant I Cl Vault j Cl Vault Privy I Cl Composting Toilet
0 Recycling, Potable Use Cl Recycling I 0 PltPrlvy I Cl Incineration Toilet
0 Chemical Toilet 0 Other
! Ground Conditions Depth to 1" Ground water table I Percent Ground Slope
i
Final Disposal by ll Absorption trench, Bed or Pit I a Underground Dispersal I 0 Above Ground Dispersal
Cl Evapotransplratlon Cl Wastewater Pond I C Sand Filt er
a Other
Water Source & Type pi.well I 0 Spring I [J Stre am or Creek I 0 Cistern
0 Community Water System Name
-
Effluent Wiii Effluent be discharged directly Into waters of the State? 0 Yes A_No
-
I
I
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and addit ional 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
o f the application; and the issuance of the permit is subject to such terms and conditions as deemed
ne cessary to Insure compliance with rules and regulations made, information and reports subm itted
herewith and required to be submitted by the appli cant are or will be represented to be true and
co rrect to the best of my knowtedge 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
fu rther understand that any falsification or misrepresentation may result in the denial of the
a p pl ica tion or revocation of any permit granted based upon said application and leg a l 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.
$;? Q_ 5 hA"""' ~vi:~ t<> {;);.i / / s-
Property Owner Print and Sign Date /
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
2.3 .00
APPROVAL
~tr!/
DATE