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RECEIVED
MAR 21 2018
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-8212
www.ga rfield-countv.com
Gørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
TYPE OF CONSTRUCTION I
tr New lnstallation Alteration tr tr
WASTE TYPE T
Dwelli E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIEI
Property Owner:
Mailing Address:
Phone:L LüY
Email Address:qáã
Contractor: Phone
Mailing Address:
Email Address:
Englneer:Phone: (_)
Mailing Address:
Email Address:
PROJECT NAME AND TOCATION
Job Address:tb¿lbß lfulf ffz 4a/L-'laþ /r't Í?/¿27
Assessor's parcet Numbe n Z7ît 3//ØI? s"a.Lot Block
Building or Service Type:rat*a/¿/fBedrooms:GarbageDisposal(Y/N) tU
D¡stance to Nearest community Sewer System , Oil, Z mi/¿ ç
Was an effort made to connect to the Community Sewer System:4ò
Type of OWTS E SepticTank E Aeration Plant E Vault E vault Privy u Composting Toilet
E Recycling, Potable Use E Recycling E tit trivy E lncineration Toilet
E Chemical Toilet E Other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
FinalDisposalby E Absorption trench, Bed or Pit Ef underground Dispersal E Above Ground Dispersal
E Evapotranspiration E wastewater Pond E Sand Filter
E other
Water Source & Type tr Well E Spr¡ng E Stream or Creek E Cistern
Ef Community Water System Name h ran t t1 /¿,
Effluent Will Effluent be discharged directly into waters of the Statê? E Yes {¡'lo
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
niandatory and additionaltest and reports as may be required by the local health de.paÌtment to be
made and-furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and'the isóuance of the permit is subject to such terms and conditions as deemed
necessa'ry to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tö 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 falsifiðation or misrepresentation may result in the denialof 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.
Property Owner Print and Sign
OFFICIAL USE ONIY Ëô 4gl /8 Fþ* 'l#t\ooq
Special Cond¡t¡ons:
'öåä-*Perk Fee:Total Fees:675,oG Fees Paid:
cð e5i, oo
Building Permit
Rrçp-::r.^;q
Sept¡c Perm¡t:
ÊtrDG.:l1oô
lssue Date
N3.
Balance Due:6d. oo
/
BUILDING/ PLANNING DIVISION:¿-2
Signed Date
%ax Bn'*,,4fr,ff Awr/ /2so w)ry'.