HomeMy WebLinkAboutApplicationGarfield County
itecovECCommunity Development Department
108 8th Street, Suite 401
r1V: Glenwood Springs, CO 81601
COUST� (970) 945-8212
OMMu-60•1411f
1N 1N 141OEVE 14'www Barfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
_
New Installation
•
Alteration
•
Repair
WASTE TYPE
Dwelling • Transient Use
■ Comm./Industrial
j
• Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: y„L1'[]tY[�r�(\ Phone: (°1(`]) 451Q---3\ 4 J
Mailing Address: £.Q `HT1 V�} c�lr >.fi 'DY GNAD CCS B\
Email Address:\ 0k(' C� 'mC i Cx
Contractor: 'r%
Mailing Address:
•
Email Address: -1/4
Engineer: C\INC iS \r019.� �n i►f1 C �f [f �Phhone: (COOO) q/- 7 c jc--)ot
Mailing Address: e � I Z GirCtin� IF�H' -a)c) pc 81 Lei
Email Address: o'1►r'\5 YVn C\C tcC5; c.0\
Phone: (11i() ) 51
PROJECT NAME AND LOCATION
Job Address: P Lt �Ce11
Assessor's Parcel Number: 2 (S ��(P I 0 O 5'ub.- .P_,fT a-wot Block
Building or Service Type: re -sic -0-y-40---' I, #Bedrooms: ,3 J Garbage Disposal
`
Distance to Nearest Community Sewer System: T 1(1/1.11,t,
Was an effort made to connect to the Community Sewer System: VI 0
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
'Septic Tank
0 Aeration Plant
O Recycling, Potable Use
O Chemical Toilet
0 Vault
0 Recycling
0 Vault Privy
0 Pit Privy
YE,
❑ Composting Toilet
0 Incineration Toilet
0 Other
Depth to In Ground water table
O Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
Underground Dispersal
0 Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
O Other
Well 0 Spring 0 Stream or Creek 0 Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? '13 Yes
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.
1 hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required informatio )which is correct and accurate to the best of my knowledge.
rop$rty Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
23-0o
Perk Fee:
X16 -
Total Fees:
/2 .0v
Fees Paid:
/23.00
Building Permit
/01-E- 61q 3
Septic Permit:
Spr- yiggl
Issue Ont,.:
5V 1v° >,
Balance Due:
tatuiv BLDG DIV: I I r! 10
APPROVAL DATE
pbe`I23,00, I04T-, Ig