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Garfield County ONSITE WASTEWATER
TREATMENT SYSTEM
{OWTS)
Community Development Department
108 9th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
PERMIT APPLICATION
TYPE OF CONSTRUCTION ,,
D New Installation I D Alteration I A Repair
W,ASTETYPE
,
~Dwelling I D Transient Use I D Comm./lndustrial I D Non· Domestic
fO Other Describe
INVOLVED PARTIES
Property Owner: _.....,;o:;;...""'""""......;;;.-bo''--.:J-..==---------Phone: ,,,__..._ __ ...__,_....i...~:--=='-'"-1 2
Malling Address: ___ ....._""-__._ ___ __._-=-------........,....._.......,""""'.....;;.o,----=-----
Engineer: """""",.,.L"""'"'::.L.14-...w;.,.......ll::;i...~"--~=--......,µ&...1-f--1-....q..--Phone: ( ___ -~....c..-......;;;.---==~
Mailing Address: _____________________________ _
Job Address: ~~:Z..,$:.:;L-~~~~..t....-E:.~L__,~Ll.~~rta:.::::JL.a....£==:~~~
Assessor's Parcel Number: Sub . /V# Lot 4 Block __
Building or Service Type: #Bedroo'!'? i Garbage Grinder~
Distance to Nearest Community Sewer Syst ; : _ ___,,,,..c_____.111.__.._l_.~ .... ~----.,.,...--------
ect to the Community Sewer System: __ /O __ O ________ _
TypeofOWTS D Aeration Plant D Vault D Vault Privy D Composting Toilet
D Recycling, Potable Use D Recycling D Pit Privy D Incineration Toilet
D Chemical Toilet D Other _______________ _
Ground Conditions Depth to l Ground water table-----Percent Ground Slope ------
Final Disposal by Absorption trench, Bed or Pit Cl Underground Dispersal D Above Ground Dispersal
D Wastewater Pond D Sand Fiiter
Cl Other _________________________ __
Water Source & Type Well D Spring 0 Stream or Creek Cl Cistern
Effluent Wiii Effluent be dlschar1ed directly Into waters of the State? D Yes
C::ERTIFICA TION
App licant aclC nowledges that the completeness of the application is conditiona l 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.
; ( 1~ I ,~-
Date
OFFICIAL USE ONLY
Special Conditions:
Total Fees: OC> ~%:-
Fees Paid:
~ ?{S"; 00
Perk Fee:
~
Balance Due:
~ ee Bulldlng Permit
~
Septic Permit: Issue Date:
3.':50.\S"
DATE