HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
le70l94s-82!2
www.ea rfi eld-cou nW.com
TYPE
WPE OF CONSTRUCNON
New lnstallat¡on E Alteration tr î
Dwelli El Transient Use tr Comm,/lndustrial tr Non-Domestic
Other Describe
INVOTVED PARTIEi -4 I
Phone:
i
I
Propefi
Malling Address:
Email Address:
contractor: " 51¿-l' v , Phone: (.,q?l ?/87 S7/,<'
Mailing Address:
Email Address:
Encineer: Phone:
Mallins Address:
Email Address:
)(
Was an effort made to connect to the Community Sewer System .4-/Ò
Garbage
Lot
PRO'ËCTNAMEAND
Job Address:
Assessor's Parcel Number:álê5l3jjoêlo"À5ub.
Building or Service Type:
Block
D¡stance to Nêarest Community Sewer System:
.ElSepticTank E Aerat¡on Plant El vault El Vault Prlrry n CompostingTollet
E Recycllng Potable Use EI Recycling tr Plt Pr¡vy E lncineratlon To¡let
E Other
Type of OWTS
E chem¡calTo¡let
Ðepth to 1$ Ground wâter table
-
Percent Ground SlopeGround Conditions
JãAbsorption trench, Bed ot Pit E Underground Dispersal t AboveGround Dispersal
t Wastewater Pond E Sandr¡herE Evapotransplration
Final Disposal by
E Other
,[l.wett [1 Sprlng E StreamorCreek E CisternWater Source & Type
tl Community Water System Name
lMll Eff,uent be discharged dlrectly into waters of the Stete? E Yes ,E NoEffluent
.R\*
CERTIFICATION
Aoolicant acknowledges that the completeness of the application is conditional upon such further
r-riOãoiV ãn¿ aOOit"¡onal test and reþorts as ryay be required by the local health de.partment to be
r"ãäã à"¿'t"rnisned by the applicant br by the loóal he.alth department for pu.rposed.of the evaluation
ääf,ã ãópl¡ðat¡on; and the ¡såuance of thé permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance with rules ånd reguìations made,.information and.reports submitted
f,ãie*iifr'an¿ required tö be submitted by theapþlicant are or will b.e represented to be true and
äıir"èt io inã Ueit of my knowledge and belief ànd are designed to be relied on by the.local
ãéóãrtmeni of heakh in'evaluatin[ the same for purposes of issuing the permit appliqd for herein. I
fuïñ"i unO"istán¿ that any falsif'r'cation or misreþre'sentation m.ay result in the denial of the
àîdi¡ätió" óiievocat¡on of any permit granted based upon said application and legal action for perjury
as provided by law.
)oe-\
I hereby acknowtedge that I have read and understand the Notice and Certification above as well as
have which is correct and accurate to the best of my knowledge.
t
Property owner Pr¡nt and S¡gn Date
OFFICIAT USE ONLY 06
Special Cond¡t¡ons:tt
Pald:ooTotal Fees:s.a+g.æPerk Fee:
s/.i¿1. ooooPerm¡t Fee:8l%,
Balance Due:
ı01,Ô
lssue Date: | -nl:v:l l()
Septlc Perm¡t:
Sr.rtr- sQôlo
Building Permit
fì rYrp-,.SØ\
-l
BU¡tDING/ PTANN]NG DIV]SION:
Slgned Approval
I
Date
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