HomeMy WebLinkAboutApplicationi, , Ci s Garfield County
- Community Development Department
UMF LLD COUNT' 6 108 8th Street, Suite 401
MUNITY DEVELC Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
❑ Dwelling
0 Other Describe
0 Trans'ent Use
161,
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
iitr Comm./industrial
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: i=AeST5A N K, LLC_
Mailing Address:
11 ❑ t' D uv,P,$ ANE:
Phone:(
5rk w(g, A51'E'')1 (0 1G I \
Contractor: DcS+;r.) , LLL•
Mailing Address: GLY10 ir. Mama \ITU AUG ,
Phone: ( ) 1`18--4-113
. Az 55251
Engineer: \1GN COVftni.'1 L^JCai,vdt,,MAX,
Mailing Address: n1-4 6LAy,€ RVQ P.
5v ‘rE"
Phone: (4116) 1H5— Z(.1.6
Cc 61601
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: 1L1b5 3&H oG 1 Sub.
EN -N-(5
Building or Service Type: Corn.,wAgL
Distance to Nearest Community Sewer System:
#Bedrooms:
1, boo fit' t~T
Lot 1. Block
Garbage Grinder =
Was an effort made to connect to the Community Sewer System: 1 L'!7 (an,`Y
Type of OWTS
Septic Tank 1 D Aeration Plant
O Recycling, Potable Use D Recycling
0 Other
El Vault 0 Vault Privy
0 Chemical Toilet
0 Pit Privy
too 4 i RaM AJC Rik atuak
0 Composting Toilet
0 Incineration Toilet
Ground Conditions
Depth to 1" Ground water table U'
Percent Ground Slope 1. K
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal
O Evapotranspiration
O Above Ground Dispersal
0 Wastewater Pond 0 Sand Filter
0 Other
Water Source & Type Well 0 Spring 0 Stream or Creek 0 Cistern
O Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 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 l 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.
Digia ly signed by Michael Fa
ON cn Michae Fa,o M.DesignFusion,LLC,
au Developer's PM. email mracsdesignrus:onbiz,c U5
Date: 2015.08.14 0913 10 -0700'
Michael Fa
Property Owner Print and Sign
August 14, 2015
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
11)3 .004e
Perk Fee:Total
-N4
Fees:
21.3. o0
Fees Paid:
213 • (SD
Building Permit
. . ' ermit:
Issu Da e:
iIHK-
Balance Du
,i1L.
#
BLDG DIV: - I W.1.�
`
APP '•.•
DATE
pe -i- /11 -PD, 14t533q(Piglitlic