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HomeMy WebLinkAboutApplicationC1TV EI` jU1 z VI ' ! Garfield County GARFkELD CO. a 5l;Ml]f�ki' DFJEI-0PM �ammunity Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.earfield-county.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION a9 New Installation ❑ Alteration -A. Repair WASTE TYPE r Dwelling 0 Transient Use 0 Comm./Industrial ■ Non -Domestic • Other Describe INVOLVED PARTIES Property Owner: 1-t.k err Mailing Address: ()i 15 Cnuri q rd 9)01 Contractor: Phone: ( c110 ) c -P4 `6 Para chi I-2. , (' Phone: (q70) ) T'8-972 Mailing Address: Engineer: Pc ti rho( 1 ' 2 Phone: ( 910 ) 2I0 - oc) Mailing Address: 155 1 W . tno(ep ertt.Lei,j- Grand o n,CU 61505 PROJECT NAME AND LOCATION Job Address: C,! ; r , trk r d 6.araC Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Sewer System: Was an effort made to connect to the Community Sewer System: Sub. Lot Block #Bedrooms: 3 Garbage Grinder - Type of OWTS Ground Conditions Septic Tank I 0 Aeration Plant j © Vault 0 Vault Privy 0 Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy ❑ Incineration Toilet b Chemical Toilet Z Other Depth to 1 Grp ound water table Percent Ground Slope Final Disposal by O Absorption trench, Bed or Pit finUnderground Dispersal 0 Above Ground Dispersal O Evapotranspiration I 0 Wastewater Pond 0 Sand Filter D Other Water Source & Type ❑ 1ell : 0 Spring f 0 Stream or Creek 0 Cistern Community Water System Name Effluent , Will Effluent be discharged directly into waters of the State? Yes 0 No 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 have provided the required information which is correct and accurate to the best of my knowledge. -1-47-vn /n/ Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: .. •60 Perk Fee: Tata' Fees: �r'OU Fees Paid: C Du Building Permit Septic cr Permit:Issue c ate: Ii2!IS' Balance Due: BLDG DIV: �J 72. i 6 - APPROVAL DATE ix( 1-c-oox,kst