HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
.® New Installation -
WASTE TYPE
Nt Dwelling rtrrransient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
Repair
Tr: Comm./industrial 1 0 Non -Domestic
7
Property Owner: -XttwL4.$ 4- Wei e7t �eIG,&-&-s Phone: ( el / 0 ) (C1 Ce — (OW
Mailing Address: 'Dl1 — \VV} eGIYOC✓Y -43--Q-, 0.o *lagiMk.oD3
Email Address: yQ.G11tft-L1N Da psy1 L„ \ ' t�3VY�
�i _�} —
Contractor: Phone: ( )
Mailing Address:
Email Address:
Engineer: ( 1(P to \rS\i4X1r1 r 7[J1 \ \a\V'leSs Phone: (410) — , 1
Mailing Address: Vim'/ a 1'I 9- V `Q 0 S-� (4
Email Address: ( W0 .31 -)C. iiYA 1iLiD 1y1\ A IVvyS, �� L vV\
PROJECT NAME AND LOCATION
Job Address: / 13
_. -
-_--
C?- Ii61.311-140041). I De ea ��rl�4cU�- [ (-) U7 73—- -
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
0 6Pave- Lot 1B Block
S VIC `7I Y.I �o�.z.'Ct ICad #Bedrooms: Garbage Disposal(Y/N)
Sewer System: (S 0( YY)1.\ L -.
to the Community Sewer System: G
Type of OWTS
Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use ; 0 Recycling i 0 Pit Privy i 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Depth to 1st Ground water table Percent Ground Slope
1
Final Disposal by
0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
_____
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter —
❑Other — ..--_
Water Source & Type
12 Well 0 Spring 0 Stream or Creek 0 Cistern
❑ 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 required information whic ct an ccurate to the best of my knowledge.
rty Owner Print and Sj
Date
OFFICIAL USE ONLY .
Special Conditions:
Permit Fee:
123. oo
Perk Fee:
150.00
Total Fees:
21-3. oo
Fees Paid:
243.0o
Bulldin Permit
( -1a01
Septic Permit:
s r- bop
Issue D te:
IiN7,020•
Balance Due:
PLANNING DIVISION:
A
�/*IIBUILDING/ 1�2�
Signed Approval Date
PD.* 113.00, Y#' I43, 11 3 9q