HomeMy WebLinkAboutApplicationGarfield County
MAR 17 lO16 Community Development Department
108 8`h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYKE OF CONSTRUCTION
If New Installation
WASTE TYPE
Oje Dwelling 1 ❑ Transient Use
0 Repair
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 7L'i47i-9kz/7C 4 4-- e__ Phone: (Q7go) 4 .0- H//a
Mailing Address:.'''/ 174177.57 e r' 4 .L4,q ,,f. 4 �c] 6/ic/,O .5 5, g/64,
Contractor: C c- / Y Phone: ( )
Mailing Address: �i G
Engineer: Phone: ( )
_
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 3y/ .1-4/of s s71rr .0 h'
Assessor's Parcel Number: Sub. Lot Block
/
Building or Service Type: #Bedrooms: / Garbage Grinder//6
Distance to Nearest Community Sewer System: f%ir / _6 -
Was
Was an effort made to connect to the Community Sewer System: AG -
Type of OWTS
IYSepticTank I 0 Aeration Plant 10 Vault
0 Vault Privy I 0 Composting Toilet
❑ Recyding, Potable Use
0 Recycling
I 0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to ft Ground water table
Percent Ground Slope
Final Disposal by
IB'Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
-d'Well
0 Spring
0 Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 1 o
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.
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.
/y< 5) c
Property Owner Print and Sign
�.. /7- /AC'
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
12-3 - �v
Perk Fee:
1 cD .0-D
Total Fees:
2?3 • ov
Fees Paid:
Zl-3.(20
Building Permit
Lr -g-- - 73
Septic Permit:
/P -1v42)14
Issue Dete:Balance
3I/1
il (e
Due:
BLDG DIV:
,�� 3 1Y-4
L DATE
pd.21-34701 VIsA-, 3lPr-Ijt,