HomeMy WebLinkAboutApplicationGurfield CountyRECENED
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Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(97Ole4s-8212
www.garfield-cou nW.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
E New lnstallation El Alteration tr Repair
WASTE TYPE
tr Dwelling El Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Phone: ß05 | ulq+ ld, ll
q1 d
EmaitAddresr, nAl€ Q r 4.IT, M)W\
Contractor:Phone: $lf) SlLl |qn
Mailing Address:6
Email Address:n¡*i,n
Engineer:Phone:
Mailing Address:6
Email Address:
PROJECT NAME AND LOCATION
Job Address:
Assesso/sParcelNumber: s"ø.M*AY Block-
Building or Service Type:s #Bedrooms: f Garbage Disposal(Y/N
Distance to Nearest Community Sewer System:Nt)fi¿
Was an effort made to connect to the Community Sewer System:
Type of OWTS p Septic Tank E Aerat¡on Plant E vault El vau¡t Pr¡vy Composting Toilet
E Recycling, Potable Use E Recycling tr P¡t Pr¡vy E lncineration Toilet
E chem¡cal To¡let E other
Ground Conditions Depth to 1"t Ground water table Percent Ground Slope
Final Disposalby E Absorption trench, Bed or P¡t E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pondl E Sand Fi¡ter
Other L C tlrFÞ l^rllflr
Water Source & Type E Well E Spring E StreamorCreek E Cistern
I
p Community Water System lUa-e
Effluent Will Effluent be discharged directly into waters of the State?El Yes r{ *o
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have the required information which is correct and accurate to the best of my knowledge.
f-t-tq
nt and Sign Date
Applicant acknowledges that the completeness of the application is conditional Vpgn such further
nìándatory 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
as provided by law.
w/oo,t1
OFFICIAL USE ONLY
speciarconditi""T*rr,
1" $ñg6ç1 7** %8*unn
Total Fees:
t27.00
Fees Paid: lzz,ooPerm¡t Fee:
t23.oO
Perk Fee:
ENb
Balance Duel
øsØT-6?A
Septic Perm¡t:lssue Date:
Õ/ p.l',lLqBu¡ldinB Perm¡t
ELR7-5?31
BUILDING/ PLANNING DIVISION:
l
Date