HomeMy WebLinkAboutApplicationktaill‘11
�� Community Development Department
�° C 14t �� 108 8th Street, Suite 401
GPt t $�1'�r �� id���` Glenwood Springs, CO 81601
(970) 945-8212
www.garfi eld-countv.com
Garfield County
TYPE OF CONSTRUCTION
0 New Installation
TE TYPE
welling D Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Alteration
0 Repair
O Comm./Industrial J 0 Non -Domestic
INVOLVED PARTIES
Property Owner:
Mailing Address: t
Phone: ( )
Contractor: 6 11.1
__ Phone: (
Mailing Address:
Engineer:
Phone:
}
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: !Ji Lz,vm7
Assessor's Parcel Number:
Sub.
Building or Service Type: 11 Vv' 1 ,t
#Bedrooms:
Lot Block
Garbage Grinder_
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Aeptic Tank I 0 Aeration Plant I 0 Vault
0 Vault Privy I 0 Composting Toilet
O Recycling, Potable Use 0 Recycling 1 0 Pit Privy I 0 Incineration Toilet
O Chemical Toilet i 0 Other
Ground Conditions
Final Disposal by
Depth to 1" Ground water table
IPercent Ground Slope
Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration
O Other
Water Source & Type 0 Well I 0 Spring
%Community Water System Name
O Wastewater Pond ' 0 Sand Filter
0 Stream or Creek
Effluent
❑ Cistern
Will Effluent be discharged directly into waters of the State?
0 Yes
CERTIFICATION
_ l
Applicant acknowledges that the completeness of the application is conditional upon such u rther
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.
hereby acknowledge that 1 h ve read and under and the Notice and Certification above as well as
avec'
r urided requ'fed in •rmatioo which is c!rrect and accurate to the • -st of my nowledge.
Property Owner Print and Sign
Date
0 ICIAL USE ONLY
Special Conditions:
Permit Fee:
`. DO
Perk Fee:
:
Total Fees:
lc. D0
Fees Paid:
CO
Building Permit
Septic Permit:
51
Issu a
Balance Due:
BLDG DIV: 41.
- - 9-/-2-05—
APPR.40 DATE
• ic•070, g 31 IS