HomeMy WebLinkAboutApplicationlie. Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www..g_arfield-county.com
TYPE OF CONSTRUCTION
0 New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Alteration
0 Repair
WASTE TYPE
IX Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
PARTIES--{
/ Phone: (77 ) 2 71- -Z.)/ Z., 3
IINVOLVED
Property Owner: 4 • 6°/l J)1 .7 ra.� N e. -Je'
Mailing Address: / C5 (1)4•1117' 'x)4.1+17' QsA Ati Z/ /J L .0140-5-
Email Address: :.4 /iv//..)://e34.__,_4_,„,:5,,, „lei -
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:. _ . Cr 4 Add , Phone: ( i 21))_7 0 5 - 3 z
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Contractor: - ti c-
Mailing Address: e../.,e4 L.2..:)—(7,5f A (2Y 1e Y2�
Email Address: 5.4'0, i. yc Ace? e? . eco 41
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Engineer: Phone: (, )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
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Job Address: c'7 C"4
�e-,
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub. T r4 city Lot 13 Block
JU cid
�ry2/7`24,ride,,ell
94J // #Bedrooms: c Garbage Disposal(Y/N) y
Sewer
to the
7 /
System: ,P2d `
Community Sewer
System: /I(/'
Type of OWTS
Pit Septic Tank 0 Aeration Plant 0 Vault
I 0 Vault Privy D Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Ground water table
Percent
Ground Slope
Final Disposal by
AckAbsorption trench, Bed or Pit
0 Underground Dispersal I 0 Above Ground Dispersal
❑ Evapotranspiration
r 0 Wastewater Pond 1
0 Sand Filter
❑ Other
Stream or Creek
Water Source & Type
Nj Well
0 Spring 0
0 Cistern
❑ Community Water System Name
1-) -?
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 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. 1
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.
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Property Owner Print and Si ri [ �J
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Date
/;2-C1-17
OFFICIAL USE ONLY 0
Special Conditions:
Permit Fee:Perk
Fee:
Total Fees:
Fees Paid
Building Permit
Septic Permit:
SgpT- • V-
��
Issue Date:
1 ---le " 11-
'�
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Balance 0
C 6- 2-.)/7
BUILDING/ PLANNING DIVISION:
—
d Approv- Date
9v.klks'.coo r c,) Ix. II-
PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs. potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object. and additional submissions in
support of this application such as data, plans, specifications, statements and
commitments. 1/0.40/
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