HomeMy WebLinkAboutApplicationp�G 41..0
1101'} . N
TYPE OF CONSTRUCTION
IR New Installation
WASTE TYPE
Dwelling 1 0 Transient Use
0 Other Describe
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: ► 4 Ag.-, 1(.1
Mailing Address: f
Phone: (gr11) gWEe-4l
&AsI+ Ca
Email Address:
Contractor: • ant, Yt Orsi eaA a ia- rutt.'r'
Mailing Address:. 14'7 orf IZ iaivty
Email Address: Jot"' A b Q Sc p r i s e
Phone: 070) 3'7T - YS`I r
S OO caJ wt V1 ss Cc.
Engineer: G a vi it O S+), j Phone: (P? O ) 309 - 5o1 S• cf
OI',+•' �; d c' Ftd�a l� L6 glia).3
Email Address: cAr I dt [s All SeV it cpfic_ 4 t1 c+ ;net
Mailing Address: 33 F'v. li) h sue G -
PROJECT NAME AND LOCATION
Job Address: 45-R, ' N,.v'+.1 is ?- C(E.&i&) each Cor 1A35 Cj e.'
Assessor's Parcel Number: 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
RI Septic Tank j 0 Aeration Plant I 0 Vault ❑ Vault Privy I n Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions
Final Disposal by
Depth to 1st Ground water table Percent Ground Slope
Absorption trench, Bed or Pit
vapotranspiration
❑ Underground Dispersal 0 Above Ground Dispersal
O Sand Filter
0 Wastewater Pond
O Other
Water Source & Type
Effluent
Well
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes ix 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 provid d the required information which is correct and accurate to the best of my knowledge.
JLAt 1� 13 LA e c.i:I i
Prop Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees: 12,3
'
Fees Paid:
...--
unit
O i f410
OW-
Septic Permit:
5�'- -7,I
Issue Dae1
1J
Balance Due:
BUILDING/ PLANNING DIVISION:
+
/2 ! �2 i 7
Sig ed Appr•
Date