HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www,ga rfield-cou nty. Com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION _ T_
]li 'New Installation - ❑ Alteration ii 0 Repair 1
WASTE TYPE
®' Dwelling I ❑ Transient Use 1 ElComm./Industrial ' ❑ Non -Domestic
0 Other Describe
INVOLVED PARTIES _
Property Owner: [D 1•r)__�j. �1 �' Phone: 9'9 la ro
Mailing Address: _2\03 T"T" ,- ,s � j '-i 7
[�
Email Address: ,r` � � 61 .Q ,a5 -3t 'i 0,9 'r ` 14-‘ - +
Contractor: AuLesrGvaCi+i Phone:
Mailing Address:
Email Address: t -4-' 11.k." t c", c" ke 5 5 Ci l 0 (1.e < ° "
Engineer: i+ P is•. yiete1✓ Phone: t`]u -) `'Q5
Mailing Address: S-010 00:..44 (n LclL 1 5- 4'
Email Address: 1 i' I A W ,),„ Ku% OA 41 '('-4 SG c u PI"
PROJECT NAME AND LOCATION
Job Address: ( l- e•c k. b Fu -.
Assessor's Parcel Number: 2. ?` l IC 5 t6c./JSu''
bf
(
Building or Service Type: 'Res' 5'i & e k C ,02 #Bedrooms:
Distance to Nearest Community Sewer System: )1,// >•" {{
Was an effort made to connect to the Community Sewer System:
Lot Block
Garbage Disposal(Y/N)
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank
0 Aeration Plant
O Recycling, Potable Use
O Chemical Toilet
0 Vault f ❑ Vault Privy
0 Recycling
0 Pit Privy
Composting Toilet
0 Incineration Toilet
0 Other
Depth to 1st Ground water table
®-ftbsorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal
❑ 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 61TO
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon curb 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. I
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
Las provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
hav[rovid:d he quir in m ion which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
133. 00
Building Permit
gag 5131p
Perk Fee:
Septic Permit:
SC ?f- 51 -3 -1 -
BUILDING/ PLANNING DIVISION:
Total Fees:
/J3. co
Issue Date:
515-19
Signed Approval
FA.t I? -3 00) vii5lg, 4130111
Date
30 //
Fees Paid:
P3 00
Balance Due:
0°
Date