HomeMy WebLinkAboutApplicationGarfield County j
Community Development Department
108 8'h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
EI New Installation
WASTE TYPE
RI Dwelling 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Alteration
0 Repair
Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: t}1?-g-li LAD It IV Phone: (69- )
Mailing Address: V'- CY . SIO A. 3 a$-- DSL Z. TV TC----.)cit-5 743g-37-
98"3fiContractor:
/
E%c,
Contractor:N -L -a..._ --b 6 ecu Li t>
Lf_C Phone: (`% fib ) b t g - Z-} Lo7
Mailing Address: tie C,tJTV, Rt7. 2 1 "4 k W C, -rLcr !C3 8'1 to 11-'
Engineer: i P Nci- c ern -'-A
1
Phone:
TE5ets-C�t
(4 ) 3oy'- 5-29
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 37iiiZ_ iatut t.- FlzcN 1 PPCF.J New C-+4-rtCcs . 9'k, =%
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
e
Sub. Lot Block
7&. 4.-C4-�Hnos #Bedrooms: 3 Garbage Grinder
Sewer System:
connect to the Community
5— Irttl es
Sewer System:
rLo
Type of OWTS
Al Septic Tank I 0 Aeration Plant I 0 Vault
0 Vault Privy I 0 Composting Toilet
0 Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
0 Chemical Toilet
0 Other
Ground Conditions
Depth to 1't Ground water table
7
Percent
Ground Slope -0—
Final Disposal by
)2 Absorption trench, Bed
❑ Evapotranspiration
or Pit
0 Underground Dispersal ! 0 Above Ground Dispersal
(Filter
- 0 Wastewater Pond ❑ Sand
❑ Other
P. Well 1
Water Source & Type
❑ Spring ! 0 Stream or Creek 1
❑ Cistern - --- —
0 Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? ❑ Yes pr. No
' CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon suchTurther
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 th r= • uired information which is correct and accurate to the best of my knowledge.
r< �� ism
Property Owner Print and Sign
If/(7/5--
Date
OFFICIAL USE ONLY
Special Conditions:
1441 % itt?. L I 2H/ 2w41uN-li AA?,
Pernfit Fee: Perk Fee: Total Fees: Fees Iris.:
IC OD 1 .t3D 171 . DO Da
Building Permit
BLDG DIV:
APPRO
Se • tic Permit:
Issue D 41ieUIi:: r
��J
VII-. '1-K ave✓$ 3z127 I1II1-I1s
Balance Due
/J' / 1.6( -
DATE