HomeMy WebLinkAboutApplicationce Garfield County
Community Development Department
108 8tti Street, Suite 401
Glenwood Springs, CO 81601
1 0iS (970) 945-8212
www.garfield-county.com
PE OF CONSTRUCTION
New Installation D Alteration
WASTE TYPE
D Dwelling-=-I D Tr ~ient u-se
Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS}
PERMIT APPLICATION
D Repair
I Engineer: ____________________ Phone:( ___ --------
1 Mailing Address:------------------------------
PROJECT NAME AND LOCATION
Job Address: /.Z.4--3 I S-m:'k f!?j_ ~
Assessor's Parcel Number: et':17 ~ -2 7 ~ ::.Sub. Lot Block ()0 ,-vu31 ---------::z-
Building or Service Type:O __ tll_Tr ________ #Bedrooms : .,...ef ____ Garbage Grin~r'_
I
Distance to Nearest Community Sewer System: ___ t .... Z .... 11_£_f?c,t __ lf'YL __ _,,__---------
I Was an effort made to connect to the Community Sewer System: _,,.r-46-6"~ ............ -________ _
Type of OWTS J ptlc Tank 1 0 Aeration Plant l 0 Vault l 0 Vault Privy l 0 Composting Toilet
D Recycling, Potable Use D Recycling D Pit Privy D Incineration Toilet
0 Chemical Toilet
Ground Conditions I Depth to 1• Ground water table-----Percent Ground Slope _____ _
Final Disposal by orptlon trench, Bed or Pit D Underground Dispersal D Above Ground Dispersal
Water Source & Type ~ell_ D Sp~~g -J D Stream or Creek [o Clst_e_rn _______ ----t
-f D Community Water System Name
jemuent ----Wiii Effluent be dlscharg_ed_d-lr_e_ct_Jy-ln_t_o _w-at_e_rs_o_f t-h-e -Sta_t_e_? __ D_Y_e_s --......-~---
..
GERTIEIGAOON
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 U,?b~formotlon whkh Is corre:d accurate to the~~ ;ledge.
Date
Special Conditions:
Permit Fee: .,,, ~ Perk Fee: Total Fees:
E'tJCn $~.oo Fees Paid: oO
V> {:)8. -
Building Permit BalanceD ~
~-
Issue Date:
I
DATE I