HomeMy WebLinkAboutApplicationcG; Garfield County
I Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970} 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
-:S.. New Installation I D Alteration I D Repair
WASTE TYPE
LJ!il Dwelling I D Transient Use I D Comm./lndustrial I D Non -Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: __ .,._i.:..r-=e;=::.....:....__.a::=.~Ji~GJ:..:H:..;._ ______ Phone: (.....:......::.....;..._ """";.......<;-----~
Mailing Address: /cP 5 5 C/2 /0 7 C,u..>J &
Contractor: ~(>J f'-/ i!:K Phone:( ___ --------
Mailing Address: ______________________________ _
Engineer:
Mailing Address:------------------------------
Assessor's Parcel Number: ________ Sub. _________ Lot ___ Block
S '~? 3 . Building or Service Type: --t:.-,..LL--"'---------#Bedrooms: _____ Garbage Grinder _.L_
Distance to Nearest Community Sewer System: _6--/ __ · .... m .......... 1t._·..,t:<: ... .., ____________ _
Was an effort made to connect to the Community Sewer System: --i&--=-----------
TypeofOWTS ptrc Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
0 Recyctrng, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
0 Chemical Toilet
Ground Conditions
Final Disposal by orptlon trench, Bed or Pit D Underground Dispersal D Above Ground Dispersal
0 Wastewater Pond D Sand Fiiter
Water Source & Type D Spring 0 Stream or Creek 0 Cistern
D Community Water System Name _________________ _
Effluent Will Effluent be discharged directly Into waters of the State? 0 Yes
-.
CERillFICATION
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
information which is correct and accurate to the best of my knowledge.
?fa/ls-
Date J
OF.FIOAL USE ONl!Y
Spetlal Conditions: .
Srz.t.. >tf>ftm .(luy '1UJ1f Ptr of ltetfro~') cit 1G/fr/ U'}// 17l1ns
Permit Fee :
1.-~·0D Fees Pa1d1;t';. OD
Balance Due : Building Permit ,. '4CJ1...-Septic Permit:
..,, "3foD3>
Issue Date:
BLDGDIV: £/)..~~ , ; ~
APPROVAL DATE
~IS