HomeMy WebLinkAboutApplication_ Garfield County
Community Development Department
108 8"' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Et New Installation
❑ Alteration
0 Repair
WASTE TYPE
CI Dwelling J 0 Transient Use 0 Comm./Industrial 0 Non -Domestic
b Other Describe
INVOLVED PARTIES �{{ _
Property Owner: i�;[.rtII c...c �� , L Phone:
I('170 1 3 -
611 )30•AA-- e Of v<— law �wr�42 LO �}I %23
Mailing Address:
Email Address: +1l G rk.w +..ar Q. kr-A, Cam
Contractor: .:cl`sre Phone: (470 ) j HS' �?`J
Mailing Address: `165 C £u—h ICA t IAf,"1•\-3( (n 9160 1
Email Address: ' V•1-`43ero1^ ( r"Lk• Isa•0
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION t
Job Address: 1-11 ❑ —b � A7� iv l �cx-. t- Cl„) c V( 3
Assessor's Parcel Number: 24 6303`1 'I `Sub. PV •JJ Lot (3 Block J
#Bedrooms: Li Garbage Disposal(Y/N) ,r
Building or Service Type: S f
Distance to Nearest Community Sewer System: avw
r��'t✓�
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank
❑ Aeration Plant
0 Vault
0 Vault Privy i n Composting Toilet
❑ Recycling, Potable Use
O Chemical Toilet
Ground Conditions
O Recycling
0 Pit Privy LEI Incineration Toilet
0 Other
Depth to 1st Ground water table 1
Final Disposal by
O Absorption trench, Bed or Pit
Percent Ground Slope
tit Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond 1 0 Sand Filter
O Other
Water Source & Type
Effluent
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 IPLNo
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. 1
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 information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I2. 00
Perk Fee:
jrb. Ott
Total Fees:
fl3: bO
Fees Paid:
2-7-3. G0
BuildinPermit
[ L . IT
Septic Permit:
Sept -5)x-1-
Issueate:
0(1`1lg
Balance Due:
BUILDING/ PLANNING DIVISION:
i
r
r 571 12pfig,
Signed Approval Date