HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-82L2
www.garfield-countv.com
TYPE OF CONSTRUSTION
tr New lnstallation
WPE
El Alteration tr tr
Dwelli E Transient Use tr Comm./lndustrial Non-Domestictr
E Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Address:
Email Address:
(-V\¿.è- KqiJ lËovrr Phone:
La-^L
c-["^I e"L Co-
cP 9t ø5>
Contractor: Phone: (-)-
Mailing Address
Email Address:
Phone:549¿'vl J^Engineer:
C/I-L
Mailing Address
Email Address:
v w"bb
PRO'ECT NAME AND.TOCATION ,
Was an effort made to connect to the Community Sewer System:N'D
Garbage Disposal(Y/N)_Building or Service Type:
ØA Block
-
Distance to Nearest Community Sewer System:
Job Address:
Assessor's Parcel Number: 8J-J4{ê#ê¡}4t¡r6.
,*'o.*--#Bedrooms: '1
þ SeRticTank E Aeration Plant E Vault E¡ vault Prlw Composting Toilettl
E Recycling, Potable Use E Recycling tr Pit Privy D lncineration Toilet
Type of OWTS
E Chemical To¡let EI other
Ground Conditions Depth to lst Ground water table -"/-01-f Percent Ground Slope 1**b-h
F Absorption trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration El Wastewater Pond
E other
E stream or CreekSwettE Spring E cistern
E Community Water System Name
Water Source & Type
Effluent
E Sand Filter
FinalDisposalby
Will Effluent be discharged directly into waters of the State? E Yes No
Applicant acknowle.dges that the completeness of the application is conditional upon such further
mandatory_and additional test and reports as may be req'uired by the local healttr department to be
made and furnished by the appllcant or by the loðal healih department for purposed'of the evaluation
of the application; and the isóúance of thri pèrmlt ls subject to such terms aird ðonditions as deemed
necessãry to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the apÞlicant are or will be represented td be true and
correct to the best of my knowledge and belief ànd are designed to be relied on by the local
depaFtment of health in'evaluatinfthe same for purposes oi issuing the permit appÍie¿ for herein. I
further understand that any falsifiıation or misreþre'sentation may-resuli in the d'enial of the
application.or revocation of any permit granted based upon said a'pplication and legal açtion for perjury
as provided by law.
I hereby acknowledge thât I have read and understand the Notice and Certification above as well as
have provided the which is correct and accurate to the best of my knowledge.
z-3
Pro Owner and Sign Date
Special Conditions:
ooPermit Fee:oo Perk Fee:oo Fees Paid:(ooO oo
Buildfng Permit Septic Permit:
Total Fees:
lssue Date:
oo\
Balance DIAv
BUITDING/ PTANNING DIVISION:
Signed Approval Date
5/31/2023