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HomeMy WebLinkAboutApplicationGarfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com RECEIVE® 2014 lyrir GARFIELD CdM011TY TYPE OF CONSTRUCTION ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION jit New Installation WASTE TYPE ❑ Alteration © Repair ❑ Dwelling 0 Transient Use ❑ Comm./Industrial I El Non -Domestic Other DescribeeA.3JAX-- Gl INVOLVED PARTIES ,(���� Property Owner: ., LT r t 41,,„ ,, _ ' Phone: l(�S.LI Mailing Address: _p, a sox 33 8(( 6�6 f�-�r-55 CCS gm e r Email Address: OR ,t: (�% /-nA- & , (.> A Contractor: £7t1.) ii..)f*-I_ Phone: ( Mailing Address: Email Address: Engineer: iii, Phone: ( ) Is Mailing Address: Email Address: PROJECT NAME AND LOCATION / t r Job Address: 5 80 ,iv . %) ALGi4 t--P'r,-) 7t , � r 12c`.}21) Sub. i7 , Block Assessor's Parcel Number:0 Building or Service Type: , (-1,1,1:--4.3 # edr o RSCms: 2.... Garbage Disposal(Y/N) 1% IJ Distance to Nearest Community Sewer System: JA. I Was an effort made to connect to the Community Sewer System: 1\J /A Type of OWTS Jt' Septic Tank ❑ Aeration Plant 0 Vault 0 Vault Privy Composting Toilet —0 Recycling, Potable Use ❑ Recycling ❑ Pit Privy 0 Incineration Toilet ❑ Chemical Toilet El Other Ground Conditions Depth to 1n Ground water table 9O/ Percent Ground Slope Final Disposal by r Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal 0 Evapotranspiration 0. Wastewater Pond 0 Sand Filter 0 Other Water Source & Type Well 0 Spring 0 Stream or Creek 0 Cistern ❑ Community Water System Name Will Effluent be discharged directly into waters of the State? 0 Yes XNo Effluent 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 required information jhich i o �on accurate to the best of my knowledge. o f I v,.o, - Crg Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: 17'3• OD Perk Fee: I O. Do Total Fees: 1.1,-Oo Fees Paid: 2 as Building Permit Septic Permit: , %+ 6EFT-- 51 Issue Date: Balance Due: /Y BUILDING/ PLANNING DIVISION. I + QQ � �`) O 20 a✓� S : Date ned .. ..a} . I rp. #2i-3. oO f 14 is - 3,