HomeMy WebLinkAboutApplicationGarfield Counly ONSITE WASTEWATER
TREATMENT SYSTEM
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PERMIT APPLICATION
CommunitY DeveloPment Department
to8 8tt'Street, Sulte 401
Glenwood SPrlngs, CO 81601
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www.garflelC-cpuntv.com
t]E Alteratlonlnstallation
Non-DomestictrEl Transient UseDwel
El Other Describe
Malling Address la¡
Phonet
Emall Address:
Property Ownerl
Fhone:Contractor:K;Ë,3
ErrallAddress:-fç-ffanTi.r"lnffi
MalllngAddress:lv.Fr' 8"r_Õ
Was an effort made to connect to the Communlty Sewer System:
Percent Ground SIoPe
Ground Conditions
Phone¡
t
Vault
iE
tableDepth to 1d Groundwater
Tollet
To¡letlncineratlon
Bulldtn6 or Servlce TYPe:
Distance to Nearest communlty Sewer System:
Englneer:
Malling Address:
Emal¡ Addrêss:
Tank
Potable
VaultPdW
PltPrtvY
Assessoy's Parcel Number:
Job Address:
ryþ1 ôf
El,.che_ltilcal t-oJlet
roü$9¡sryrsalPltE underground Dlrpersalorqêd
Water Source &TYPe
FllterPond
Olher
clstern
Yesw¡ll Effluent
Wâqtqþ,atêr.E
of !h9 ltate?lntowatersbedlrectlydlscharged
Stream or CreekSprlng
Water System Nama
Effluent
I hereby acknowledge that
have provided the requíred
Property Owner Print and Slgn
PP l? à oo,ßl?rþrnl{
I have read and understand the Notlce and certiflcatlon above as well as
informatlonwhlchiscorrectandaccuratetothebestofmyknowledee.
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Date
lg
Speclal Conditlons:
Fees Paid:lza ttTotalFees¡ ¡a-{Åt, è tPerk Fee¡6?ôoP€rmlt
Balance Due:ls3ue Dat€¡
Bulldlng
4uløø
BUTLDINC/ PLANNING DlVlSloNr
Slgned Approval Date