HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation
WASTE TYPE
f Dwelling
0 Other Describe
-
0 Alteration I Repair
0 Transient Use 0 Comm/Industrial1 0 Non -Domestic
INVOLVED PARTIES ��
Property Owner: Wht iN dM._ r•� 1 I Phone: (6 7"�) 5[� I 11 11
Mailing Address: -,"i /Ih'1 �iiZ ��1 {c
Email Address:
Contractor: cc LAC'
Phone: ( 470 i r Z`I
Mailing Address: 12 L A) "�. s r jL � • 7_- t hf )J? LA --)C [ � 51 t. C. I (o • $'rtG�'�
Email Address: e if( t) S�y(E'r0•rc^
Engineer: („L i< CuLi Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: _ 115 r rr61 Vi 5 'i
Assessor's Parcel Number: Sub.
Building or Service Type: R-01 Dc. #Bedrooms:
Lot Block
Distance to Nearest Community Sewer System: 51 L I S 1-4 r L r S
Garbage Disposal(Y/N)
Was an effort made to connect to the Community Sewer System: AIL)
Type of OWTS
Septic Tank ] ❑ Aeration Plant 0 Vault 0 Vault Privy L 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 it
Percent Ground Slope
Final Disposal by
fit Absorption trench, Bed or, Pit j 1t1 Underground Dispersal ! 0 Above Ground Dispersal
1 �
O Evapotranspiration
0 Wastewater Pond To Sand Filter
O Other:
Water Source & Type
Effluent
11 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 id No
f Perk Fee: i s �\
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 w 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.
m
Property Owner Print and Sign Date
OFFICIAL USE ONLY
special Conditions:
Per Fes:
Building Permit
Total Fees:z2.„5.--
Sep c P+mit: — Issue Da
BUILDING/ PLANNING DIVISION:
Fees Paid! n' �
Balance Due:
Signed Appioral Date