HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
RECEIVED 108 8th Street, Suite 401
Glenwood Springs, CO 81601
APR 13 2018 (970) 945-8212
ARFIELD COUNTY www.garfield-caunty.com
GCOMMUNITY DEVELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation pis Alteration
WASTE TYPE
tit Dwelling 0 Transient Use
0 Other Describe
Repair
0 Comm./Industrial
❑ Non -Domestic
Property
:ES QAGG7eg at f� Phone:
Pro ert Owner: �7 _ Ali l�`V�.Mailing Address: 3p 36I �6c4,
Email Address:
Contractor:
Mailing Address:
Email Address:
) r7d- 22F
Phone: ( )
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: - J�j ///+
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 1* Septic Tank 0 Aeration Plant 0 Vault I 0 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 Depth to 1St Ground water table lI Percent Ground Slope
b° , Absorption trench, Bed or Pit 0 Underground Dispersal
Final Disposal by
O Evapotranspiration 1 0 Wastewater Pond
❑ Above Ground Dispersal
}
0 Sand Filter
O Other
Water Source & Type
Effluent
O Well
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes
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 provided he3equired ••F form ion which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
Date
OFFICIAL USE A.'—f. 4, C.Y� 1064 13 cam - 7�.� 00
Special Conditions:
Permit Feer O�
� -
Perk Fee:
I
Total Fees: O O
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Fees. Paid: QO
4W' 75.
Building Permit
A
Septic Permit:
Date:.
Issue Date:
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Balance Due.
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nT 51' 0
BUILDING/ PLANNING DIVISION:,•-.
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5 gi ned Ap 1 Date
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