HomeMy WebLinkAboutApplication111__'1 M14k 11
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE
WASTEWATER
SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
Q Dwelling
0 Other Describe
L; Alteration
0 Repair
0 Transient Use
❑ Comm./Industrial
1 0 Non -Domestic
INVOLVED PARTIES
Property Owner: Sao) ' Phone: 1?'/ 3 }- Pfd -_4e/ 3 2 -
Mailing Address: /G)26 CGLvr lye ., /v2 C112, g "VI mss`
Contractor:
Mailing Address:
Phone:(
IPROJECT NAME AN
Job Address: /I7 C) Wil 'lam /''
Engineer:
{
Mailing Address: 0
ft-kk 4/019-4
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: (—wA J 0 diroirwr #Bedrooms:
Distance to Nearest Community Sewer System: "Lf 114. -
Garbage Grinder
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank 0 Aeration Plant 1 ❑ Vault I 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use 0 Recycling I 0 Pit Privy E
❑ Chemical Toilet 0 Other
0 Incineration Toilet
Depth to 1" Ground water table
Absorption trench, Bed or Pit
0 Wastewater Pond 1
Percent Ground Slope
0 Underground Dispersal
O Evapotranspiration
O Other
0 Above Ground Dispersal
0 Sand Filter
Web 0 Spring 0 Stream or Creek
O Community Water System Name
0 Cistern
Will Effluent be discharged directly into waters of the State?
�d69 e,ttc -- 604-
0
.nd.
❑ Yes
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 infprtrnation which is correct and accurate to the best of my knowledge.
4- -2-2- ;5
Date
Property Owner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:Perk
qS• W
Fee:
Total Fees:
1-C. DO
Fees Paid:
9-S• 60
Building PirZt _g
5e_ pticr-
519
Issue
pate:
17.
Balance Due
BLDG DIV:
"'"-
` S 4A--/5-
APPROVAL DATE
1- 1
riJ '4°214
C5:04Y
?oh'
spection Nu Insp Project chedule Dat 'nary Inspec :heduled Tin spection Ty! Status teinspectior Completed Priority
INSP-23849 <NONE> 6/4/2015 Provost, Ma Final Passed so w• 0
INSP-23391 <NONE> 5/27/2015 Wilson, ]im Final Partial - Pas J 0
INSP-23392 <NONE> Inspector, C Perc Test None 0
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