HomeMy WebLinkAboutApplicationREC El Garfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
ommunity Development Department
GARFIELD COUN T 10s at11 Street, Suite 401
MMUNITY DEVELOPMEN Glenwood Springs, co 81601
(970) 945-8212
www.garfield-county.com
h'P.E OF CQNSTRUGrlON
li2r New Installation I D
WASTE1'YPE
Alteration
PERMIT APPLICATION
---I D Repair
-----IB' Dwelling I IJ Transient Us e I D Comm/Industrial I D Non-Domestic
D Other Describe
INVOLVED PARTIES
. --
-Hettt.e.-~ (~ • ..,..._ , ~. v-.......... ii-.-
Contractor: & O'.ll i::;c:.1;11.1;:d. II:
_,
Phone: ( zid ) ~~ £-l:J z~
Malling Address: :Poli? U.!l6 CL:T'M w.e:a::i:s: C ~, C"Q FCld.l.~
Engineer: .i I A Phone: ( ) ,
Malling Address:
PROJECF NAME AND LOCATION ·---
Job Address: .llr~9" /7.-... -"" /.)_~ .2 fr/<°. A/-' L',.---H-e:/1 .t;-~Lc/~
s:E (
Assessor's Parcel Number: Sub. Lot Block
-·-
Building or Service Type: #Bedrooms: 3'. Garbage Grinde~
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
TypeofOWTS liil Septic Tank I a Aeration Plant ,. a Vault I D Vault Privy I a Composting Toilet
0 Recycling, Potable Use D Recydlng j D Pit Privy I D lndneratlon Toilet
0 Chemical Toilet a Other
Ground Conditions D/pth to l n Ground water table I Percent Ground Slope
Final Disposal by l:J Absorption trench, Bed or Pit j D Underground Dispersal I D Above Ground Dispersal
D Evapotransplratlon a Wastewater Pond I a Sand Fiiter
I D Other
~
Water Source & Type !ill Well ] 0 Spring I D Stream or Creek I D astern
0 Community Water System Name
j Effluent Wiii Effluent be discharged directly Into waters of the State? D Yes ~No
GIRTIFIGAii0N
Applicant acknowledges that t e completeness of the application is conditiona 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 ar e 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 i nformation which is correct and accurate to the best of my knowledge.
~ 4::-"' ?-LK --<C//7" Prop; -OWne;.;;;and Sign Date
Spedal Conditions:
Issue Date: Balance Due:
BLDG DIV• ~
AP PR OVA~