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GCANMED
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
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ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
i` Dwelling 0 Transient Use 0 Comm/Industrial
0 Alteration
0 Repair
Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: tuxr rr+ CR nerd Phone: (Sri 0 ) -qo
Mailing Address: b iZio-.0.- (.31 13 .L. ,, \ 11_&. e riX , $ ((,+ 7
Contractor: t,th. --to -.' Phone: ( 90 ) q i l' marc
[. .-1m r .cl. Gt . ci (4.1,c. ar-t al . Si st.5
Mailing Address:
Engineer: Phone: (
S Mailing Address:
PROJECT NAME AND LOCATION
Job Address: --(Q)
_ 3 -
Assessor's Parcel Number: 3 Ac3o.Sub.
Building or Service Type: #Bedrooms:
Distance to Nearest Community Sewer System: ,)' '`i 1 1 e..
Was an effort made to connect to the Community Sewer System: ( d
Lot Block
Garbage Grinder
Type of OWTS
fl Septic Tank 0 Aeration Plant ,1 0 Vault
O Recycling, Potable Use 0 Recycling
D Vault Privy 0 Composting Toilet
0 Pit Privy 0 Indneratlon Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1t Ground water table
Final Disposal by IJrAbsorption trench, Bed or Pit
Water Source & Type
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal [
0 Above Ground Dispersal
0 Wastewater Pond r 0 Sand Filter
O Other
Well 0 Spring 0 Stream or Creek I 0 Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes
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CERTIFICATION
App icant acknowe'ges that the completeness of the application is conditional upon suc 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
ded the required inf gnation which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
P>�ov1d a egg 'Keeled Sgsi'ewl, 1051/1104101 h pp>rvw l ,P -'O Peer Ivo/c/o,
Permit 40
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Perk Fee:NG
F-
Total Fees: �o
vn�
j
Fees Paid: ,.,e1- ^
1y�/,arrf�1
Building Permit
SI ilriF- 519--
Septic Permit:
Issue Da
J AI N
Balance Due: OO
T5"5
5�P - &5k
BLDG DIV: 0 /..
APPROVAL DAT
1,aft'-15- $1t3°
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