HomeMy WebLinkAboutApplicationGarfield County 1
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TV E OF CONSTRUCTION
New Installation
0 Alteration
0 Repair
WASTE TYPE
Dwelling DITransient Use ❑ Comm./Industrial j 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES _ (�[�
Property Owner:M �L.}" ��{e f Phone: {�Q } ! U
Mailing Address: 1505 o,vt f`(�1'A7 Pr rrt�- y�f s C 1 to C) 1
Email Address: w6tbbt4 vJC l+e�3() t'ko+w1C3) . co � q
Contractor: �U,r WA 141-4.15 % i , Phone: ('170)-5 7 1 -5 7
Mailing Address: (j 7 5 C f5�, C0 V'J 5r t.o S1 (pa J l�
Email Address: 11/1 W"( �"�C�' S e-4 -pC( V Lj • -� � 9 '710 ADL 1,
170.-3VI -5257
• r COE rop,ldaI,/ co
FIU23
Engineer:
Mailing Address:
Phone:
Email Address:0A(1.01
Servic 5.e p f ic.. cor1
PROJECT NAME AND LOCATION
Job Address:. 22 pp
Assessor's Parcel Number: 2.-i ( �� 1'��5ub.��" " Lot 2_ Block
Building or Service Type: SH #Bedrooms: Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank
■ Aeration Plant
O Recycling, Potable Use
O Chemical Toilet
❑ Vault 0 Vault Privy
O Recycling
0 Pit Privy
0
Other
Composting Toilet
0 Incineration Toilet
Depth to 15t Ground water table
O Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal
O 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
Will Effluent be discharged directly into waters of the State? 0 Yes
0 No
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. 1
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.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
Y} ya e p�i� the required info
11'
Property owner Print and Sign
hi
rrect and accurate to the best of y knowledge.
Date
OFFICIAL USE ONLY j,`n/ 8/02.08 l/asQO' U54.
Special Conditions:��
molt Fee: Qa,
3.
Perk Fee:
NC
To al Fees:
x(23-�
Fees Paid:
1123,E
Building Permit
i4L-
Septic P mit:
�� •
Issue Date
iii 131
•
Balance Dug:
10 B
BUILDING/ PLANNING DIVISION:
VI)
' ///3"26/4
Signe . pproval Date