HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
RE
APR 2
3$,i[l'-v
Community Dwelopment Department
E ?018 to8 8ù street, suite 401
^ ¡^ñt ¡¡1$lenwood Springs, CO 81601
H'Vñıtn¡rHT (e7o) e4s'8212
wumr.garfi eld-counW.com
TYPE OF CONSTRUCTION
New lnstallation EI Alteration tr Repair
WASTE WPE
tr Dwelling E Transient Use tl Comm./lndustrial tr Non-Domestic
Other Describe
INVOTVED PARTIES
I
PropefiOwner:
Mailing Address:
Email Address:
Mailing Address:
Email Address:
Phone: f )Contractor:
Engineer: Phone:
Mailing Address:
Email Address:
)I
PRO¡ECT NAME AND TOCATION
Was an effort made to connect to the Community Sewer System:
Job Address:
fr"*,
0 SubAssessol's Parcel Number:
Building or Service Type:
D¡stance to Nearest Commun¡ty Sewer System:
#Bedrooms:Garbage Disposal(Y/N) g-VÊ-Bbck-hG
El Vault Prlvy Compostingþ Septic Tank El Aeration Plant El Vault
E Rit Privy E lnclneration ToiletE Recycling, Potable Use El Recycling
E chem¡cal Toilet E other
Type of OWTS
Percent Ground SlopeGround Conditions Depth to 1d Ground water table 'l
f, Underground Dispersal E AboveGlound DÍsþersal-'SAbsorptlon trench, Bed or P¡t
E Sand FilterE Wastewater PondE Evapotransp¡ration
FinalDisposal by
E other
Water Source & Type
Effluent
Cistern
NoState? E YesWill Effluent be discharged directly into waters of
Community Water System Name
Well Spring Stream or Creek
CERT¡FICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
niindatory and additional test and reports as may be required by the local health depa_rtrnent 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 submÍtted 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. l
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 understand the and Certification above as well as
have provided the required ts to the best of my knowledge
e 9ü',/Itr
Property Owner Print and Sgn Date
ro 1'T7 ca,zsúi7 L1-tg
OFFICIAT USE ONIY
Special Conditions:
Total
Dt)
Fees:
77V
Fees Paid:"L1?" ao
Permit Fee:
l1,b,?rs lÇ0, ut>
Perk Fee:
lssue Date:
IR
Balance Due:,dBuilding Permit, ,
fuà Lol¡¡l/h¿l
Seotic Perm¡t:
StT'6b[4 .=
Date
BUTTDTNG/ P|¡NNING DrvrSlON: