HomeMy WebLinkAboutApplication[1: -
Garfield County
Community Development Department
108 8d' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.Aarfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE �..
12/ Dwelling 0 Transient Use l7 Comm/Industrial i 0 Non -Domestic
0 Other Describe
0 Alteration
j ® Repair
I—INVOLVED PARTIES
Property Owner: n r r*k,
Mailing Address: ( lr e. •
Contractor 'j
Phone: (9`1 ) ' auf.
Phone:
•
Mailing Address:
Engineer: ' pX1; } rw C Phone:O) ? `i '_
Mailing Address: -115. ka."81/v) LA Vie' ' . M Q-0 `f;
PROJECT NAME AND LOCATION
Job Address: ':. • _. C'
Assessors Parcel Number. -ta Sub. Lot '5 Block
Building or Service Type: #Bedrooms: Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect�to the Community Sewer System:
Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
O Recycling, Potable Use 0 Recyding 0 Pit Privy 0 Indneration Toilet
O Chemical Toilet
❑ Other
Depth to 1 Ground water table 1: _ Percent Ground Slope
O Absorption trench Bed or Pit
O Evapotranspiration
0 Underground Dispersal
0 Above Ground Dispersal
0 Wastewater Pond ' 0 Sand Filter
Other Sgg
iWeu - 0 Spring
0 Stream or Creek
❑ Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes 131410
CERTIFICATION
Appficant 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. 1
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 here knowledge th
have ' • ed the requi
nd understand the Notice and Certification above as well as
which is correct and accurate to the best of my knowledge.
Property
Print and
S r
2/1 /1r)
Date
OFFICIAL USE ONLY
-
Special Conditions:
Permit lee: co
4.75=
Perk lee:
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Total Fees:
%7 -S -.°a
Paid:
00
?s -
Building Permit
kISt
Septic Permit
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Issue
1/17/0 }1�
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APPItp a DATE
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