HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfieid-county.com
TYjE OF CONSTRUCTION
lP( New Installation
rsTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
Dwelling 0 Transient Use 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Ww1ra_c Phone: ('7, ) Z7'/ - 3Z.7'
Mailing Address: Zo0c> GA-i.e. j1;, U,, - f or4, Pen Lien, CO V O 7 -02 -
Contractor: 3G C..14s4+ c 1 ,v+ 'oveoiedraw, Phone: (c}7a) 374i - G43E
Mailing Address: 700 1-40.03.a. L*.p, C .go rtc{u la. , CO SIC Z�
Engineer: // _ Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: P's. ct .•-, ,.P 100Kdip. IC.. CO a/ 141.3
Assessor's Parcel Number: 2391- 24+{-05- OI b sub.5i4-114.3 v./r'.3 Kc h Lot l C Block
Building or Service Type: I�cS 1.41r- 'CQ. CS►447 )1#Bedrooms: Garbage Grinder 4_
Distance to Nearest Community Sewer System: Aajo ox; 401.1Jt)y 1.15 M; /
Was an effort made to connect to the Community Sewer System: rrJJ JU Q
Type of OWTS
SepticTank 0 Aeration Plant 0 Vault D Vault Privy 0 Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy D Indneration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to e Ground water table Dicer Percent Ground Slope
Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Fitter
Final Disposal by
Water Source & Type
Effluent
O Other
O Well
0 Spring
0 Stream or Creek 0 Cistern
"(Community Water System Name .5f. -Ji nA c- 4.
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. 1
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 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.
(1JJL evil rs
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
X23 • by
Building Permit
BLDG DJV:
Perk Fee:
E%U
Septic Permit:
seer- 3111 -
Total Fees:
f 7-3.00
issue Date
S ' S
pA.4ft3.ut',
Fees Paid:
13• DO
Balance Due:
/0/5--
DATE %