HomeMy WebLinkAboutApplicationCommunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.Rarfield-countv.com
TYPE OF CONSTRUCTION
10 New Installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
VI Dwelling 0 Transient Use ❑ Comm/Industrial
0 Other Describe
❑ Repair
0 Non -Domestic
INVOLVED PARTIES_
Property Owner: 1. rcr
lef-fe)-1.
Mailing Address: " 0
Contractor: / P
Phone: (q7/1 ) 379 — 70 2.
Mailing Address: 572.43c.e
Phone: (
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
_ s
Job Address: }67 ft
oal
Assessor's Parcel Number: 2,z9sciipSub.
Building or Service Type: Ai,. /4'+,7
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
p wi- Lot 2_ Block
#Bedrooms: Garbage Grinder T
Type of OWTS
E _
Ground Conditions
IF Septic Tank ❑ Aeration Plant
D Recycling, Potable Use
❑ Chemical Toilet
0 Vault 0 Vault Privy 0 Composting Toilet
0 Recycling 0 Pit Privy 0 Incineration Toilet
0 Other
Depth to 1� Ground water table f } Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type Well ❑ Spring 0 Stream or Creek D Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? D Yes No
Effluent
CERTIFICATION
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
hav - Drovided t — req red information which is correct and accurate to the best of my knowledge.
Prope
Owner Print and Sign
3 —16 is r --
Date
OFFICIAL USE ONLY
Special Conditions:
_lei c[ud & Fv-ture, d rc ms lyi 5YS1wi Siziall VytM, 3 Bit -per plitvt S
Permit Fee:
I9-3.��
Perk Fee;Total
Fees:
1a3 cD
Fees Paid:
C-.; o
Building Permit
i - 3(7r 7-S
Septi ermit:Issu
- -3 3
�6
4.1
Balance Due:
BLDG DIV: do-rol"•---1�� ,c
APPROVAL DATE
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