HomeMy WebLinkAboutApplicationGarfield County
RECEIVED community Development Department
108 8t'' Street, Suite 401
I 7111,3 Glenwood Springs, CO 81601
GARFIELD CO
isNLI"(970) 945-8212
MEH�
COMMuHITy DEVELOPwww.garfield-county.com
TYPE OF CONSTRUCTION
New Installation
W TYPE
Dwelling I 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
1 0 Alteration
0 Repair
0 Comm./Industrial 0 Non -Domestic
r INVOLVED PART
Property Owneret./ e. 47 Dqn ie. Phone: (9/0) IA i if . el itiZ.
Mailing Address: IL.(D afi Dein ielC t3144• 4y?S(..t"_, en. 3i6 '7
Email Address: epiA.5 vrrcd i i 49 no 1. Cis Psi
Contractor: 0 w iit eP r Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: ( )
Mailing Address:
Email Address:
_PROJECT NAME A AND LOCATION �
Job Address: 34 eV (W e!fy �-- -
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub. { l(i iL tk C[ Lot tf Block
Kci DCWU r #Bedrooms: Garbage Disposal(Y/N)
Sewer System:
to the Community Sewer
System: l,(\ 16 -
Type of OWTS
J Septic Tank 0 Aeration
❑ Recycling, Potable Use
❑ Chemical Toilet
Plant I 0 Vault 0 Vault Privy Composting Toilet
{ 0 Recycling 0 Pit Privy
0 Incineration Toilet
j 0 Other
Ground Conditions
Depth to 1st Ground water table
Percent
Ground Slope
Final Disposal by
Absorption trench, Bed or Pit 1 0 Underground Dispersal ( I 0 Above Ground Dispersal
❑ Evapotranspiration
❑ Other
t 0 Wastewater Pond
L 0 Sand
Filter
Water Source & Type
Well 0 Spring ❑ Stream or Creek 0 Cistern
❑ Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes I 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 required information which is correct and accurate to the best of my knowledge.
,--Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions: 4, 9utiA444i 9hAti bt dZ�iiOr- / iN9W4€ l kly A 404%4 1i'Czho4
P.E. f'rovi4L OIV1"3 desio�n fbv Inodpv p4witu fey( shliviLiv6 fiutl w.f.:met priori C.O.
Permit Fee:
(7•••' • 00
Perk Fee:
ANG.
Total Fees:
01. ov
Fees Paid:
/73, oa
Idln�Pe�i
Ii.
tic Permit:
%rtif,P. 54141.
Issue te:
1131202D
Balance Due:
BUILDING/ PLANNING DIVISION:
�-
� �'�. �� `�
Signed Approval Date 1
131).12-1.00/ 1152,gill lf