HomeMy WebLinkAboutApplicationc::G» Garfield County
Community Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Ja New Installation I D Alteration I ....-Ci""Repair ~E -Do
WASTE TYPE
l..BJ Dwelling I D Transient Use I D Comm./lndustrial Tii Non-Domestic --D Other Describe
INVOLVED PARTIES
Property Owner:~~~~---........ ........ ----=-------Phone: (970 ) 6 B -22
MailingAddress: 184 7 /VO ).l~rvl E LAN£ C C: 12-1
Contractor: C-W !,,vg?lt.!) 12 1fS )Cl:{
Mailing Address: _.f._._o._. _,i3:;...;;;.0X........___.---=..::;..i.;"--_,_"""""".r.........;;:....:.:::..:=--..:........i.~:..=L=--'G:7'=='-.Jo.B..:...:...l::::.(;-==2.....;;;;~;____
Engineer: ---'~...:....;.,...:::..r:..L...L___,L--..,.,._.......,,~....<.:1.!~;...._-1-..c:~~--==---Phone: .......... -=--
Mailing Address: ---'-+-'""'""'--__...,F-lf-'-'~.._---------------------
PROJECT NAME AND LOCATION
Job Address: l/ {)
00.3
Assessor's Parcel Number: Z. 1173 2Jeo Sub.---------Lot ___ Block
Building or Service Type: Ho M £. 511./Ct.!L frl7Y1 #'tlctrooms: _:3 ___ Garbage Grinder_
Distance to Nearest Community Sewer System: _ __._N...._.h......_/li...._ _____________ _
Was an effort made to connect to the Community Sewer System: _N,_.._tA ........ ._ _______ _
TypeofOWTS
Ground Conditions
Final Disposal by
~ Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
0 Recycling, Potable Use 0 Recycling 0 Pit Privy D Incineration Toilet
0 Chemical Toilet 0 Other _______________ _
Depth to 1' Ground water table-----Percent Ground Slope ------
Ji!P Absorption trench, Bed or Pit D Underground Dispersal 0 Above Ground Dispersal
D Evapotransplratlon D Wastewater Pond 0 Sand Filter
0 Other _______________________ _
Water Source & Type 0 Well ,R_Sprlng 0 Stream or Creek D Cistern
0 Community Water System Name ________________ _
Effluent Wiii Effluent be discharged directly Into waters of the State? 0 Yes I D
CERTIFl€ATIGN
Applicant acknowledges that the completeness o f 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 provided the required information which is correct and accurate to the best of my knowledge.
Date
OF.P.IC!IAL USIE ONl±Y
Balance Ou B Q ~.
5"-)4 .... 2..0 /.J
DATE