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HomeMy WebLinkAboutApplicationGarfield County RECEIVEemmunity Development Department 108 8th Street, Suite 401 AUG 0 8 2019 Glenwood Springs, CO 81601 GARFIELD COUNTY (970) 945-8212 r:OMM1!NITy rEVELOPMEI.. .garfield-county.com TYPE OF CONSTRUCTION ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION 0 New Installation Alteration 0 Repair WASTE TYPE 'E Dwelling 0 Transient Use 0 Comm./Industrial ❑ Non -Domestic ❑ Other Describe INVOLVED PARTIE Property Owner: , 'n Mailing Address: OM . i VCR \ Spft„,}S Email Address: !'4�Csg15,--®Quo+a. CON\ i - Phone: ()0o )3_ Contractor: 5-AmQ. Phone:( Mailing Address: Email Address: /j, Engineer: AL CV1c� (5Sb C-vib I Phone: (4 ) 6145- Mailing Address: GO 1� uJUA `` 1Jcc L\ CAvoki dbSQrubs- C.d • i) �� Email Address: i i1L el 1pt.er 9401W, t l,rn PROJECT NAME AND LOCATION SrutN�C �r t (-6- Job Address: Assessor's Parcel Number: Sub. St) \ {� j Building or Service Type: Ni-ILILI42(aYgr�. Lot Block #Bedrooms: 0 Garbage Disposal(Y/N) Distance to Nearest Community Sewer System: Was an effort made to connect to the Community Sewer System: Type of OWTS 0 SepticTank 0 Aeration Plant 0 Vault 0 Vault Privy ■ Composting Toilet 0 Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet 0 Chemical Toilet 0 Other Ground Conditions Depth to 1st Ground water table Percent Ground Slope Final Disposal by 0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal 0 Evapotranspiration 0 Wastewater Pond 0 Sand Filter El Other Water Source & Type 0 Well 0 Spring 0 Stream or Creek 0 Cistern 0 Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 0 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 h ve provided the required information which is correct and accurate to the best of my knowledge. Property Owner Print and Sign Date OFFICIAL USE ONLY Pad�1�9 41r -,890Z_ ,8 75 co Special Conditions: 1 Permit Fee:© 7-S Perk Fee: NI A Total Fees: Y� 7cS Fees Paid: OO 75. Building Permit '� Septic Permit: �s899 issue Date: gi21-111 Balance Due .40 BUILDING/ PLANNING DIVISION: '/ ► i/'� �3I g014 ,t Signed Approval Date