HomeMy WebLinkAboutApplicationGarfield County
µoit 1. 17416 Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
in New Installation
r2/1".....nE TYPE
Dwelling
ONSITE
WASTEWATER
TREATMENT
SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Transient Use 1 0 Comm./Industrial
0 Other Describe
INVOLVED PARTIES
Property Owner: AVV6
Mailing Address: 7
Contractor: Phone: (
Mailing Address:
Phone: (TM _)tcl f53
{,, d rt 1 C" /6
Engineer:
• "—
Mailing
Mailing Address: .. e) ) ;✓ Sciret, 4 J 4/.1
PROJECT NAME AND LOCATION
Job Address:
hone: ( #7e ) 7c46 '/r/
Assessor's Parcel Numb r: O3gi3Z07_001'6 Sub. Lot 1 Block
Building or Service Type: - :
#Bedrooms: , 3 Garbage Grinder RU
Distance to Nearest Community Sewer System: /CS r4
Was an effort made to connect to the Community Sewer System: '
Type of OWTS
B epticTank
0 Aeration Plant 1 0 Vault I 0 Vault Privy I 0 Composting Toilet
0 Recycling, Potable Use
0 Recycling i 0 Pit Privy 0 Incineration Toilet
0 Chemical Toilet
0 Other
Ground Conditions
Depth to 1 Ground water table
f Percent Ground Slope .dr ''
a
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration I 0 Wastewater Pond 0 Sand Filter
O -Otherr Az rjr 6 fee ./ ejtv.dg s .
Water Source & Typeh ell 0 Spring 0 Stream or Creek 1 0 Cistern
O Community Water System Name
Effluent `�� Will Effluent be discharged directly into waters of the State? 0 Yes CI
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 1 have read and understand the Notice and Certification above as well as
have provided the required information whiclryissorrect and accurate to the best of my knowledge.
06in % O L X)4 (71-
Property Owner Print and Sign
31—
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Perk Fee: Total Fees:
(A3 .00 ---- P.3-00
Fees Paid:
17-3. Do
Building Permit Septic • - it: Issue Da
-'4°4WDJj 111- 3123 1 i0
Balance Due:
0
BLDG DIV: `= � _�i�
' 3-z3-l‘e,
APPR • AL
DATE
FA. # 123. co � r✓J (015;3lIt I He