HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
geCe1\1
°) 108 8`h Street, Suite 401
Glenwood Springs, CO 81601
'1n�R q (970) 915-8212
0,1041 www.garfield-countv.com
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0I4 `U" TYPE OF CONSTRUCTION
• ❑ New Installation
I WASTE TYPE
At Dwelling 0 Transient Use 0 Comm./Industrial
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
Repair
0 Non -Domestic
INVOLVED PARTIES_
Property Owner: ped LL
Mailing Address:
Email Address:
PO . Box '-1g P5 Go
Contractor: !+ ile- (Li ep'
Mailing Address:
Email Address:
Engineer: Phone:
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: 7b;i:t:lkotis. Sub.
Building or Service Type: Dw`f'« A.r-)
Distance to Nearest Community Sewer System:
#Bedrooms:
S/6o/
Lot Block
Garbage Disposal(Y/N)
Was an effort made to connect to the Community Sewer System: 'J 0
Type of OWTS
Septic Tank
❑ Aeration Plant 0 Vault I 0 Vault Privy 1 El Composting Toilet
O Recycling I- 0 Pit Privy 0 Incineration Toilet
0 Other
O Recycling, Potable Use
O Chemical Toilet
Ground Conditions
Depth to lst Ground water table
Percent Ground Slope
Final Disposal by
jIt Absorption trench, Bed or Pit I 0 Underground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
O Other
Water Source & Type
Effluent
tit Well
0 Spring
0 Stream or Creek I 0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? ❑ 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 the required informtion which is correct and accurate to the best of my knowledge.
I:,ry,
Date
Propner Print and Sign
OFFICIAL USE ONLY
- 4)I LL Citack )4IAW% tbi' c■
Special Conditions:'/r7l K 0'4Ly
Permit Fee:__,
Perk Fee:
Total Fees:
Fees Paid:
Building Permit
Septic Permit:
l.iV
Issue pate: JO
trg
Balance Due:
BUILDING/ PLANNING DIVISION:
I
t
.;�J 5^3'20)8
Signed Approval Date
PP .( IC -00) /-}' Vi -q3) c13,11g