HomeMy WebLinkAboutApplicationGarfield County
RECEIVED Community Development Department
NPR 1 , 01� 108 8th Street, Suite 401
P'R
O
" Glenwood Springs, CO 81601
G 1E Y DO EL" ��1y www.
970) 945-8212
GoMMU garf elld cou p v.com
TYPE OF CONSTRUCTION
clew Installation
WASTE TYPE
VA -welling
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
Repair
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: / -. M :x : ' / ' " Phone: (f'7) 3�.3
� / ! . 7
,•�+•
Mailing Address: )- /7 e7if T c„Y / G%..26-) 6"--0,44,<,..4-4, L'C7 .%&-r,"f
Email Address: 4914 ICfc:.-da?//VL%4e S, c_c,/art
Contractor: C-; •'e.a, aAck.1 Crl.*:.r_c•fri."z/r'v.I Phone: (f7C) ),.:3 79 e/ ( /
Mailing Address: ,)Q , jaw .3J-?, de �urti"f= c ---c, �/‘7
Email Address: e IG G1i s' I. c led/Co, C d.y,
Engineer: : ,....,r..s igitr cc.-, ..46. t Phone: (y/a) 7e7' 0$//
.,
MailingAddress: -.4-4'2-- /774,..;e: -.52r40.,-/- ,.54_,•,..4 A, �Cl6r ce—a C� gfe 2- 3'
Email Address:F* 4,- W lc �s eras �,c. .c__ 4, et.,
PROJECT NAME AND LOCATION
Job Address: ► , ,` - .. 9 .:'
Assessor's Parcel Number:J37j 2d7 ' I/ Sub. 4 Ti{r_•,.,�rfii..,/.4. } Lot y-zBlock
I
Building or Service Type: A S 4.46 #Bedrooms: 3 Garbage Disposal(Y/N)..4 -I
Distance to Nearest Community Sewer System: .� .///,...Z
Was an effort made to connect to the Community Sewer System: .0.7'..---2:3
Type of OWTS
Iiiireptic Tank 0 Aeration Plant 0 Vault
0 Vault Privy ii Composting Toilet
❑ Recycling, Potable Use
' 0 Recycling l 0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
1;1016her -,--.e.....:--,1‘ ,s -r •doi4..,
Ground Conditions
Depth to 1st Ground water table 7 /C" i
Percent Ground Slope '-C'.52%
Final Disposal by elbsorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond f 0 Sand Filter
❑ Other
Water Source & Type
DeII
0 Spring
0 Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes l�'I
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 a knowledge hat I h ve read and understand the Notice and Certification above as well as
have pro ided the requt ed in1rmation1Which is correct and accurate to the best of my knowledge.
CEJ
Property Owner Print and Sign
)(A/
4/1-6/6 fb
Date
/
OFFICIAL USE ONLY
£D.4
Special Conditions: V
,, f. 1 5
C- /ewe.
],0-4 A x-17, h /RC./(, 2"
R 73 �-T- »- � . o ri jj
1.4
:r
Permit Fee:Perk
I 3.
Fee: r+J 6.
Total Fees:
/23.00
Fees Paid:
/73.00
Building Permit
�.
Septic Permit:
sir- 51i A
Issue Date: .
1mii
Balance Due:
BUILDING/ PLANNING DIVISIO
1
ZP
: '
v'
Sign =oval Date
123.0o� , '2-4&4 III ►$