HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
RECEIVEp Community Development Department
108 8th Street, Suite 401
AU6 tl S 20lE Glenwood springs' co 81601
l970l94s-8212
GARFIELD COUNTY- www.sarfietd-countv.com
COMMUNITYDEVELOPMENT
-
TYPE OF CONSTRUCNON
ìN'ASTETYPE
E AlterationE[ New lnstallation
tr Comm./lndustrial E Non-DomesticE Transient Usetr Dwell
E other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
v Phone:gt D- LO
p. ia. lbo.d ll.¡,lA (*A-^,!.lt (,"t. vt(.2\
Engineer:Phone:
Mailing Address:Ð Ð
Email Address:
PROJECÍ NAME AND TOCATTON
Assessol's Parcel Number lot Elock
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System
tr Above Ground Dispersal I
El sand F¡lter
E Community Water System Name
If 14 Co
Job Address:
BuildingorServicetyee:ï-qh fr-^:tI #Bedrooms: \ GarbageOisposal(i/N) y
FinalDisposal by
Water Source & Type
Lov
Contractor:Phone: I
Mailing Address
Email Address:
E other
Type of OWTS Vault
P¡t Pr¡W El lnc¡nerât¡on Toilet
Septic Tank E Aerat¡on P¡ant
Recycling, Potable Use EI Recyding
E vault Privy
E Chemical Toilet
! ComfostingToilet
Percent Ground Slope 7-.'|¿ 4Depth to 1* Ground water tableGround Conditions
E underground DispersalE Absorption trench, Bed or Pit
E Wastewater PondE EvapotranspF¿t¡on
\l/-
E Stream orCreek E CisternE SpringE well
Other
Effluent Will Effluent be discharged d¡rectly ¡nto waters of the State? E Yes [] tto
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditiona! Ypgn such further
n"iândatory and additir¡nal test and reþorts as Tay be required by the local health de.partment to be
made and'furnished by the applicant or by the local health department for pu.rposed of the evaluation
of the application; and' the isiuance of the permit is. subject to such terms and conditions as deemed
necessai'y to insuie compliance with rules and regulations made,-information and.reports submitted
herewith'and required tò be submitted by the applicant are or will be represented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatinf the same for purposes of issuing the permit applied f-or herein. I
further understand that any falsífiıation 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.
Lvt¿lt s?- ¿t i"/ìï-\ ¡,-,- L*^-LeÐ
Property Owner Pr¡nt and S¡gn Date
ffi
OFFICIAL USE ONIY
Special Conditions:
Permit Fee:
fit23.oo
Perk Fee:
EN)C,
Total Fees:
ðlea.oo
Fees Paid:
6 lZj. ou
Building Permit6Re s3gs
Septic Permit:s€?T Sj1b
lssue Date:
1/a) tn
Balance Due: n-U-
BUILDING/ PTANNING DIVISION:ahln6
DateSigned Approval