HomeMy WebLinkAboutApplicationRÉCÉNÉD
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munity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
l970l94s-82t2
www.sarf¡eld-cou ntv.com
OF CONSTRUCTION
New lnstallation
TYPE
EI Alteratíon -,tr-- Sqpi!,
Comm./lndustrial
Garfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPL¡CATION
I g Non-DomesticYE Transient Use!f=am*iø
er Describe o
¡NVOIVED PARTIES
Property Owner:
Mailing
Phone:
Ðll.ÅÊ.3 Wæs- afleenÞ.ðâs @. <w r€.sdrce.s , <<"t tYl
Engineer:
Mailing Address:
Email Address:
(-,-Phone: ( )
ß G ulÛÚ o ft C¿ sl
w n/W;"roñ
PROJECT NAME AND LOCATION
Job Address:
Assesso¡r's parcel N u m b ur, LJIZfK)WJLsua.
Building or
D¡stance to
Was an effort made to connect to the Community Sewer System:
lot I Block
-
Nlô
ç,lr- 2 7ÒÈrv(Mailing Address:BI t ftAÑ'DY (¿¡.c ø nd al<,Ca
Contractor:
Email Address:
E vault E Vault Privy Composting ToilettlE Aeration Plantp serticrank
E Recycling EI lit Rrivy E lncineration ToiletE Recycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to lsr Ground water tableGround Conditions
þ underground Dispersal E Above Ground DíspersalE Absorption trench, Bed or PitFinal Disposalby
E other
Wastewater Pond E Sand Filter
E Stream orCreek E cisternWellE Spríng
Evapotransp¡rat¡on
E Communíty Water System Name
Water Source & Type
Will Effluent be discharged directly into waters of the State?E Yes F-¡,¡oEffluent
Annlicant acl<nowlcdges that the completeness of the application is conclitional upon srrch further'"i¿iÀàäi"wän¿ a¿¿¡i¡onal test and reþorts a.s may be required by the local health de.pa-rtment to be
rãä"ìñA'trrn¡sfrÀa by the applicant br by the local health department for purposed.of the evaluation
äiìf'ã ãóËl¡ða[iın; ãnO'ti'e ¡.óúan.e of the permit is. subject to such terms and conditions as deemed
ñeiessãrV i" insuie comþliance with ru.les ànd regu.lations made,.information and.reports submitted
f'ãi"iuiti"ri'rì rãóuìrea io be submitted by the-apþlicant are or will be repres.entqd t9 bg true and
.ıir"ifi.ìf'è U"it of my knowledge and belie-f and are designed to be relied on by the.local
ããor.t-"iã":i ãf frialtfr in'evaluatinã the same for purposes of issuing the. permit applied for herein' I
trTñ"ï ,n¿"ittiñ¿ that any falsifiãation or misrepresentation may result in the denial of the
ilpii*tig.¡óiiãvocãtion of any permit granted based upon said application and legal action for perjury
as provided by law.
CERTIFICATION
I hereby acknowledge that I have read
have provided uired information
Property Owner Pr¡nt and S¡gn
rÞ /'L3 oo/2775t
and understand the Notice and Certification above as well as
which is correct and accurate to the best of my knowledge.
z9
Date
3 t7
OFFICIAL USE ONIY
cond¡tíons:"ü,ìiö''ãrol i¡+talt,ctlaø rtp+ %ttir¿,} Wir to o.o.Special
Fees Paid:lLTotal Fees:izPerk Fee:Fee: .129-
Balance Due:lssue Date:qSeptic Permit
s
Building Permit
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BUITDING/ PLANNING DIVISION:
Signed Approval Date
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