HomeMy WebLinkAboutApplication.pdfINVOLVED PARTIES
PropertyOwner: (i)(1(tir-M S. I•MI i C. MOi.4bI D1! Phone:( ) 34-(o ZZ-$$
Mailing Address: P. 0 • 13o 85 t1/41. ix) Gar sat- a g(iD -'"
LILLg t MottLToiJ
Phone: (cS *O ` k
Mailing Address: . O • 13C)-- (I 2- CI 1 LSC , Co f (Q52
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
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Job Address: 37ZfO FR.0I TA-Ae TioA.p MEtir C4sTICo SY( (p4 -
Assessor's Parcel Number: ci) S3 10(0 `iboc Ir,1j• Sub. Lot Block
Building or Service Type: ? i NLS, Di: rptmloir #Bedrooms: .. Garbage Grinder I
Distance to Nearest Community Sewer System: .2 M I LES
Was an effort made to connect to the Community Sewer System: p-(0
Type of OWTS
1 Septic Tank
I 0 Aeration Plant 1 0 Vault
I ❑ Vault Privy 1
0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
0 Chemical Toilet
0 Other
♦�---
Ground Conditions
Depth to 1`t Ground water table
Percent Ground Slope Z 1 5 !.
Final Disposal by
■ Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
• 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 sr No
Gurfield Cou,'tyJ
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
GARFIELD COUNTY (970) 945-8212
)MMUNITY DEVELOPMENT www.garfield-county.com
SEP 302014
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
1
■ New Installation ❑ Alteration
WASTE TYPE
® Dwelling 1 0 Transient Use
0 Repair
0 Comm/Industrial 0 Non -Domestic
0 Other Describe
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.
ittro4 Ailk94Q ? et (zo
Property Owner Print and Sign Date
OFFICIAL USE ONLY
1;a. 4
Special Conditions:
Permit Fee:
1 Z 3 . ao
Perk Fee:
I5a . o 0
Total Fees:
PIA 00
Fees Paid:
253. 00
Building Permit
' V
Septic Permit:
6 pr= ? off,
Issue Date:
1 ?o'14-1-
fBLDG51,x
Balance Due:
BLDGDIV: 4,eftWAA"--/ l
APPROVAL DAT
?&2S30, ✓# 00-1 -, 1.3o-14+