HomeMy WebLinkAboutApplicationcG Garfield County
Community Development Department
108 s th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER Ii
TREATMENT SYSTEM
{OWTS}
PERMIT APPLICATION
D Comm./lndustrial D Non-Domestic I 0 Ot her Describe ___________________________ _
I 2
Property Owner: Tl e Phone: ).-v-....... -"""-'--'----...;
Mailing Address ~ .. 51 ~ ~.r./sl Cu•k, D<· U:cWqle, CO 8/tzrl-l ..
Contractor: C~..\t'EJL ~ -M l>N'\T Phone:(~ ) 179 .-37Cf1 -
Mailing Address : Po !tot i.o :J-31P , $rJcwM.4J"J ~ l'-LA-t....£. CD f l fa /L ·1
Engineer: EftW CO\>• 3iLJ1 6£<=>~~El!Jl\\:FP hone: (9,7o)rt95 -n1t;, l
Mailing Address: I S-I> "1 gt.~ A \IE... #:-I 0 i • bi.JS &'"I £s 0 I .
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Assessor's Parcel Number:ciS,1-3t.1'-(CJ-DOS-Sub. ~-~tit1: f~ lot ar Block --
Building or Service Type: Rt.~ 1 J t." \-\A, I #Bedrooms: 4 Garbage Grinder _
Distance to Nearest Community Sewer System: 5" ~,,~~ I Was an effort made to connect to the Community Sewer System: NQ
Type9fOWTS ~ Septic Tank I a Aeration Plant I a V'!ult I a VaultPri~J a Compo-sting ~
C Recycling, Potable Use C _R_ecy~ling j C P~Privy [ C Incineration T~llet
0 Chemical Toilet 0 Other
Ground Conditions j Depth to 1 n Ground water table I Percent Ground Slope
I
Final Disposal by a Absorption trench, Bed or Pit I a Underground Dispersal I 0 Above Ground Dispersal
a Evapotransplratlon--1 a Wastewater Pond I C SandFllter
I a ether
Water Source & Type 0 Well I a Spring I D Stream or Creek I C Cistern
' D Community Water System Name i
Effluent Will Effluent be discharged directly Into waters of the State? D Yes C No
Applicant acknowledges that the completeness o the application is cond i tional 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 permi t 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 information whi h is correct and accurate to the best of my knowledge.
Special Conditions:
Perk Fee: Fees Paid: Q:)
$h'3.
Issue Date:
4 .Lt .\