HomeMy WebLinkAboutApplicationGarfield County
REiimmunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.Rarfiel d-cou nty, com
NOV 2 7 2011
GARFIELD COUNFY
)MMUNITY DEVELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
la New Installation
0 Alteration
WASTE TYPE
Dwelling
0 Transient Use
0 Repair
1 0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: YtrN.� 54eA,i, (ce. Phone: ( '770 ) '7ZZ' -027
'Mailing Address: 2!? 4s/ W7,7 ,t c.4, /G /o K - Ig' 6f ku,1irr 60 SSI&i
Email Address: Ia.". r'ce-LO / &f Iyf s. Cry,
Contractor: 1^1ki•k— 1-J0v 17
kt( 5 Phone: ( 7G) 27W -k`((,.
Mailing Address: /OM (44, ( (C 2;4e I& Cw o -1,(k (c) gic02 3'
Email Address:
/G�''Iu4e,ilefMh�te0/17
!
Engineer: /0/{-3 ! i <T'k Phone: ( 6r1:1 ) 3d`1- SZ
n
Mailing Address: 33 FD(.4r Ph ad Pri'.C. 12d • 6.4140.114 IC (o S10�3
Email Address: 04.4 . ns , . /.Lail
/ l
PROJECT NAME AND LOCATION
Job Address: i>*' 4 41 d 6.44,- &I(
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub. Lot Block
�/
1?•5 •,:t,-1,, i #Bedrooms:3 Garbage Disposal(Y/N) /
Sewer System: A
to the Community Sewer
,,
System: Ai
Type of OWTS
10 Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 1 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
/U4 I Percent
Ground
Slope 1
Final Disposal by
11 Absorption trench, Bed or Pit 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration I 0 Wastewater Pond
0 Sand Filter
❑ Other
TO Cistern
Water Source & Type
Ili Well { 0 Spring I 0 Stream or Creek
❑ Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 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. 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.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the req ired info ation which is correct and accurate to the best of my knowledge.
4/4. 4,0 4,- /l/Z' 742
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
IV aS, 00
Perk Fee:
Ftp_('-)
Total Fees:
4/2s, co
Fees Paid:
4./23. oa
Building Permit
NAY - soQ,a
Septic Permit:
Issue Da •
I 2-gi pr -T93.
Bake Due80
;5E 3
BUILDING/ PLANNING DIVISION:
i 1#2/16/1017
Signed Approva
Date