HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
OCT 2 0 2017 (970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
0 Alteration
0 Repair
WASTE TYPE
❑ Dwelling 1 0 Transient Use 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: C I f%tt_l fC3y1 C1r11_4 h Phone: ( ) � q, }- (2
Mailing Address: v-iAct r Qkcict€ Irl Psi e c-1 (1 Co .
Email Address: i1iiUll'("� YC1 i Ce_ rar h QJ Yu. (°oar\
Contractor: �.M 7t1`1 LAk �; Phone: ( ) 379 3C�1�Y,i
Mailing Address: k(1 -1%-I c V-kG(Q
L U "1L ( c€1W-.11
Email Address: Ll '1 %-1- 2 Kr\ . (GUNC h f G i)0 ° CONA(1
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: c95 f frik M11 '2ck 11 F, 611 nU and C-11 r 1+fIC ma. qI O 1
Assessor's Parcel Number: j)1 S c -(ID 1) il: Sub. Lot Block
Building or Service Type: #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
t Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy ❑ Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
Ground Conditions
0 Other
Depth to 10 Ground water table Percent Ground Slope
Final Disposal by
Water Source & Type
O Absorption trench, Bed or Pit
Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration
Effluent
0 Wastewater Pond
0 Sand Filter
O Other
Well
1
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes No
0 Spring
0 Stream or Creek 0 Cistern
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 . c urate to the best of my knowledge.
7r�- IT�
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
44: 00
Perk Fee:
06
Total Fees:
123 • °6
Fe Paid:
p73 00
$ /.
Building Permit
...
Septic errnit:
LIctqL/
Issue Date:
11-2 --1T
Balance Due:
,Oo
BUILDING/ PLANNING DIVISION:
S
.
(06/10 17
Signed Approval Date