HomeMy WebLinkAboutApplicationGar.field Countv ONSITE WASTEWATER
TREATMENT SYSTEM
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PERMIT APPLICATION
Community Development Department
108 8th street, Suite 401
Glenwood Springs, CO 81601
1970l.94s-8212
www.garfield-countv.com
PE OF tr RepalrE AlterationNew lnstallation
WASTE tr Non-Domesticlndustria Itr CommE Transient UseDwelli
E Other Describe
Phone:
Emait Addres$ r-V) ft,Lt)¡'/\@. 6fvwr\, ÉÊri-É
Property Owner:
Mailing Address:
Phone:Contractor:
Mailing Address:
Email Address:
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Was an effort made to connect to the Community Sewer System
Phone: (
"b. UW-fuÍV+-,o, 3 Brock-
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ND TION
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Assessor's ParcelNumb "rt Ll?í5-
Distance to Nearest Community Sewer System
Mailing Address
Engineer:
EmailAddress:
Job Address:
PROJECT
Building or Service TyPe:
-
Composting ToiletTEl Vault E Vault PrivyE Aeration PlantEzseptic Tank
E lncineration ToiletE Recycling E P¡t PrivyE Recycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to 1't Ground water tableGround Conditions
E Above Ground Dispersalon trench, Bed or Pit E Underground Dispersal
E Sand Filter[J EvapotransPiration El Wastewater Pond
E other
E cisternE Spring E Stream or CreekE/well
EI Community Water System Name
Will Effluent be discharged directly ¡nto waters of the State El/llo? EYes
Final Disposal by
Water Source & TYPe
Effluent
CERTIFICATION
Anpiicant aci<nowledges that the completeness of the applìcaiion is conclitional upon such further
;iriüi;;;;;i;;;lìiü;;;í Luri ul ã rcporm ae may hn required by the loral health rle.partment to be
;i;;;iì;ji;ilrî;îiy ir,"ãppli.inrãr by rhc loóal healih cle¡.rarrrrrerrr foI purposed.of the evaluation
of tlie application; unitÏ" ¡iíúlnce of th* permit is subject tosuch tcrms and conditions as deemed
necessary to insure ."róli;;äwlttr rul*t iìncl regu.lations made,.information and reports submitted
herewith and requtreU iı Oi *Urittu¿ þr¿ the -ap-plicant are or will be represented to be true and
;;;ä¿i"i"ih; ¡-"ï orinVr."o*lããâáand 'belief åód are designed to be relied on bv the,local
;ã;rtd;;iıfheatth'¡'n'uuriuåt¡ñfrir'.rur"forpurposesoiissuingthe.permita,ppliedforherein' I
i;,iñui ;;å.iitäräiÅåi ãnv iulrìiiËuiion or misre'presentation m,ay result in the denia,l of the
application or revocart-;;i unt 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 provi ded the required information which is correct and accurate to the best of nry knowledge.
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Property Owner Print and Sign Date
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Special Conditions andrevlew,forProvidof nspectorlsireducopydesignreqmsedesignpticsysteEngineered ofcate OccutnsCertifi pancY.&finalto ¡tdbure ing pectionnfiinstallationprioralportEngineer's
Fees Paid:
&rz3.aoTotal Fees:
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Perk Fee: ,
N/¡Permit Fee:
S t23-oo
Balance Due:.+Issue Date
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Sept¡c Perm¡t$qr-+?Building Permitgße 51al^,
BUILDING/ PLANNING DIVISION;
DateSigned Approval
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