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HomeMy WebLinkAboutApplication74. c' Garfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-countv.com • ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYKE OF CONSTRUCTION _ _ � Property Owner: gcio-1 o AAA) Phone: (M I— v-15-• 11 67 Mailing Address: 664- i- 666-IaG 1i[yic PCE. Contractor: x.;42 O )g -S t ROISD -- Phone: ( 110)I-61-.--30 3 - Ilei New Installation • Alteration • Repair W$5TE TYPE Assessor's Parcel Number: 2313 2-4-10601 f Sub. iroT7� Lot 1 Block Building or Service Type: 50.1 L„ ckruly RFS + JCL #Bedroo/ms: /-t- Garbage Grinder On C Distance to Nearest Community Sewer System: ©+1 S ai`.f J Was an effort made to connect�/WO to the Community Sewer System: Dwelling ❑ Transient Use ❑ Recycling, Potable Use 0 Comm./Industrial 0 Pit Privy 0 Non -Domestic • Other Describe 0 Other Ground Conditions Depth to ft Ground water table CTA. ff r 1 Percent Ground Slope 1I'/,i Anal Disposal by dl Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration INVOLVED PARTIES _ _ � Property Owner: gcio-1 o AAA) Phone: (M I— v-15-• 11 67 Mailing Address: 664- i- 666-IaG 1i[yic PCE. Contractor: x.;42 O )g -S t ROISD -- Phone: ( 110)I-61-.--30 3 - Mailing Address: PO Djc 1 L% (Cg ,£ Engineer: PL -L S U SCM - IKEA Phone: (970 ) 309-76-2-59 Mailing Address: A 1-6O it fHfiA- DQ.i'L, L..iki7.6tDatt C PROJECT NAME AND Ls CATION Job Address: 0 r 4.01k‘ 5 4,, •7 1: Assessor's Parcel Number: 2313 2-4-10601 f Sub. iroT7� Lot 1 Block Building or Service Type: 50.1 L„ ckruly RFS + JCL #Bedroo/ms: /-t- Garbage Grinder On C Distance to Nearest Community Sewer System: ©+1 S ai`.f J Was an effort made to connect�/WO to the Community Sewer System: Type of OWTS ® Septic Tank 1 ❑ Aeration Plant I 0 Vault I 0 Vault Privy 0 Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet ❑ Chemical Toilet 0 Other Ground Conditions Depth to ft Ground water table CTA. ff r 1 Percent Ground Slope 1I'/,i Anal Disposal by dl Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter ❑ Other Water Source & Type 0 Well 0 Spring 0 Stream or Creek 0 Cistern aCommunity Water System Name Will Effluent be discharged directly Into waters of the State? 0 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. 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. 1 hereb acknowledge that I have read and understand the Notice and Certification above as well as ha pro ided the requir d information which is correct and accurate to the best of my knowledge. Lul,A 817Ac Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: 123 .CO Perk Fee: ----- Total Fees: 123 Da Fees Paid: 123 .0c. Building Permit g3Z�S Sep W-3CM Issue gate: Q�JIc 1 Balance Due j0 BLDG DIV: r_. gZB/� APPROVAL DATE