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HomeMy WebLinkAboutApplicationGarfield. County Community Development Department eGOwf-i 108 8th Street, Suite 401 Glenwood Springs, CO 81601 �V �� (970) 945-8212 GOk3t4 w.garfield-county.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION _. -- TYPE OF CONSTRUCTION �+�JI) Property Owner: k.[LQ* V'(". i3)j Phone: (4' en) ) Mailing Address: a 1 S 3 6 CNK Email Address: C,1?._ v. et%A. e CLA ►i., ( i, . b ►� ff!-r • New Installation Mailing Address: Email Address: • Alteration • Repair WASTE TYPE PROJECT NAME AND LOCATION nn Job Address: ----1-63 6 6 fC A - Assessor's Parcel Number: Zj A/1m -- 9h D6 T I Sub. Lot Block Building or Service Type: qhcic #Belrooms: Garbage Disposal(Y/N) ,;' ( .�-r..c• Distance to Nearest Community Sewer System:] vvn-P.2.. Was an effort made to connect to the Community Sewer System: tax) • Dwelling • Transient Use 0 Aeration Plant j 0 Vault I • Comm./Industrial Composting Toilet • Non -Domestic 0 Recycling 0 Pit Privy 0 Incineration Toilet ❑ Chemical Toilet 0 Other • Other Describe Depth to 1st Ground water table Percent Ground Slope Final Disposal by it Absorption trench, Bed or Pit 0 Underground Dispersal INVOLVED PARTIES �+�JI) Property Owner: k.[LQ* V'(". i3)j Phone: (4' en) ) Mailing Address: a 1 S 3 6 CNK Email Address: C,1?._ v. et%A. e CLA ►i., ( i, . b ►� ff!-r Contractor: �J Phone: ( ) Mailing Address: Email Address: Engineer: Phone: ( Mailing Address: Email Address: PROJECT NAME AND LOCATION nn Job Address: ----1-63 6 6 fC A - Assessor's Parcel Number: Zj A/1m -- 9h D6 T I Sub. Lot Block Building or Service Type: qhcic #Belrooms: Garbage Disposal(Y/N) ,;' ( .�-r..c• Distance to Nearest Community Sewer System:] vvn-P.2.. Was an effort made to connect to the Community Sewer System: tax) Type of OWTS gt Septic Tank 0 Aeration Plant j 0 Vault 0 Vault Privy Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet ❑ Chemical Toilet 0 Other Ground Conditions Depth to 1st Ground water table Percent Ground Slope Final Disposal by it Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter ❑ Other lil Well 0 Spring 0 Stream or Creek 0 Cistern Water Source & Type ❑ Community Water System Name Will Effluent be discharged directly into waters of the State? 0 Yes No Effluent 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 have provided the required info ation which is correct and accurate to the best of my knowledge. Property Owner Print and Sign /-1 __/• Date OFFICIAL USE ONLY Special Conditions: Permit Fee: J 2 3 Perk Fee: ( Sb Total Fees: 21-3 — Fees Paid: 21-3 — Building Permit g LMF 6-5?4 Septic Permit: SEAT - 55 is" Issue Date: 17-111-115( Balance Due: BUILDING/ PLANNING DIVISION: 12/I4 7Olg Signed Approval Date p +213.00 �if- I3s1--, RI