HomeMy WebLinkAboutApplicationr, Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
I TY E OF InstallationCONSTRUCTION
,,New
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
WASTE TYPE
C.' Dwelling ❑ Transient Use
0 Comm./Industrial
0 Non -Domestic
❑ ther Describe
INVOLVED PARTIES /,�
Property Owner: VI /I� % Phone: ( 970) �U 7/ 0 2
� � ?
Mailing Address: 19/,/ If !! f rYoe r�i � �/�L�vO 5 co .`�
Email Address: 07-(1141# f��+,9 tki14, /''
Contractor: OYM? Afelifil Phone: f )
Mailing Address:
Email Address: _
(Q/ '� �25
Engineer: j�DfJi',!{� �}i1i� [JJ)I� r�lr fly(. Phone: %
Mailing Address: 923 l_D0?eY AleIt) 5Uf /e 20 / 64,,1400 GP to g `6c
Email Address:
LPROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: 23 I -1306V:(qa Co //e- [% Lot 2 Block
Building or Service Type: #Bedrooms: 7 Garbage Disposal(Y/N) Yes
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
SepticTank 0 Aeration Plant
O Vault
0 Vault Privy Composting Toilet
0 Recycling, Potable Use
0 Chemical Toilet
O Recycling
0 Pit Privy 0 Incineration Toilet
0 Other
Ground Conditions
Depth to 1SS Ground water table
Percent Ground Slope
Final Disposal by Absorption trench, Bed or Pit
Water Source & Type
0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Sand Filter
O Other
0 Spring
0 Stream or Creek 0 Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes No
CEIMIRCATKIN
Applicant acknowledges that the completeness of the application is conditional upon such further
1 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.
/fe/';
Property Owner Print and Sign
/2/2///
Date
OFFICIAL USE ONLY
Special Conditions:
Permit fFee:
Perk Fee:
Total Fees: I3 . -
Fees Paid: 1 ^
L
1d
Building Permit
PiLb b-0 44
Septic Permit.
3 —.
Iss /
r j
21203—
Balance Due:
7lr//n
BUILDING/ PLANNING DIVI5f0
: Allijri
Sign d Approva
Date