HomeMy WebLinkAboutApplicationGøffield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-82L2
www.garfield-countv.com
TYPE OF CONSTRUCTION
New lnstallation tr Alteration tr Repair
WASTE TYPE
l[ Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOwED PARTIES /4 J t l-- t¡¿ llt4
Phone:
é)
¿<¿//({t^(t tQ r'¿lC
Email Address:
ProFrerty Owner:
Mailing Address:
PhoneContractor:
Mailing Address:
Email Address:
Phone: ( )Engineer:
Mailing Address:
Email Address:
PROJECT NAME AND TOCATION
Building or Service Type:
-
#Bedrooms:
-
Garbage Disposal(Y/N)-
Was an effort made to connect to the Community Sewer System:
Distance to Nearest Community Sewer System:
Assessor's Parcel Number:
Job Address:IO-.^¿-
Sub Lot Block _
E Vault E Vault Privy I ComnostingToiletSeptic Tank E Aerat¡on Plant
[3 Recycling, Potable Use E Recycling E Pit Priny E lncineration Toilet
E Chemical Toilet E other
Type of OWTS
Depth to 15t Ground water table Percent Ground SlopeGround Conditions
E Above Ground D¡spersalE Absorption trench, Bed or Pit E Underground Dispersal
E Sand FilterE Evapotranspiration E wastewater Pond
FinalDisposalby
E other
E Spring E Stream or Creek E Cisterntr wellWater Source & Type
E Community Water System Name
Effluent Will Effluent be discharged directly ¡nto waters of the State? E Yes E No
CERTIFICATION
Aoplicant acknowledges that the completeness of the application is conditional Ypgn such further
;ti'J;ää;r;;¡-åäã''tñilíteiianã reþorts as may be req'uired by the local health de.partment to be
;;ljä;ñili|ìr¡ää ¡v 1'eãppltcant br by the loóal he.ali.h depail.rnerrl. [ur pu,rposed.of thc evaluation
ääñãäóËlìðåï¡"ü; ã"it-Èã¡iiüánðè of thé permit is.su.bject to such terms and conditions as deemed
necessarv to insure .oróiãni" *it¡ rules ånd regulatioîs made, information and.reports submitted
ilã;ıii|¡".d Ëö;ìr"d ið bË iubmitted by the-apÞlicant are or will be rep,resentgd t9 bç true and
äoiäèfioì¡" Ueü oi my tno*t"¿ge and bel¡ef ànd are designed to be relied on by the.local
ã;|]ñ;ã¡i óitrãàtil1 ¡n'evaiuatin!'the same for purposes oi issuing the.permit a,pplie.d for herein. I
trTf'äï ""¿Listånãïtrát
any fatsifiıation or misreþre'sentation may result in the denial of the
äîôiiðátî"ñóiiãuócàt¡on óf anv permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that t 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.
ob-I12 "
Property Owner Print and Sign Date
?or'\
C,<''tft
GL"c'\
OFFICIAL USE ONIY
Speclal Condltions:
Fees Paid:s\2Fees:ooTotalsPerk Fee:FeePerm¡ts Ø
ooBalalssue Date:¡t:
0s3g\b qBuilding Permit
BUILDING/ PLANNING DIVISION:
Signed Approval Date
tltzløtï