HomeMy WebLinkAboutApplication.-
Gar.field County
Community Development Department
108 3th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION --
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
-]21-New lnstalliition Jo Alteration I D Repair
WASTE TYPE
~Dwelling I 0 Transient Use i D Comm./lndustrial l D Non-Domestic
0 Other Describe
INVOLVED PARTIES
·-
Property Owner: .],I, A a.J d I.'1£. ~I~ C~ff.· Phone: ( 303 ) ~n I -.~.?,./,R
Mailing Address: 41~ ~_,~_,, ,,-&~~w. ~iLr l~' G~s-r;;J. T ,
Contractor: U ft, i::'-&,t,:::T&AV,,i/o--t Phone: (9 7t> } ~? ~ -~ (C, l ~
Mailing Address:
Engineer: Phone:( )
Malling Address:
PROJECT NAME AND LOCATION
~
Job Address: 'I (S lA,.-vL~ ](...,~ ,V ~co 5'11-r /t<> . ~/LS'2
' Assessor's Parcel Number: Ol 1.:2. 1~5"' /coo~ Sub. Lot Bl ock --
Building or Service Type: f? 6. S!. #Bedrooms: s Garbage Grind er_
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
TypeofOWTS Jil" Septic Tank I a Aeration Plant I D Vault I D Vault Privy I D Composting Toilet
D Recycling, Potable Use D Recycling J D Pit Privy I D Incineration Toilet
D Chemical Toilet D Other
Ground Conditions J Depth to 1" Ground water table tGt2. , j Percent Ground Slope
Final Disposal by RJ Absorption trench, Bed or P~t_l D Underground Dispersal 1 D Above Ground Dispersal
D Evapotransplratlon D Wastewater Pond I D Sand Fiiter
D Other
Water Source & Type ~Well I D Spring I D Stream or Creek I D Cistern
D community Water Sy st em Na me
Effluent Will Effluent be discharged directly Into waters of the State? D Yes fl No ·----·-----
CERTIFICATIPN
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 information which Is correct and accurate to the best of my knowledge.
J91h.f C.RE171 ~ al&! J/J.IJ./ll-
Property Owner Print a ~n Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: 0 P ~ Fee: ~;--~--~/, 00
To~I Fees: 00 t:tS.
Fees Paid: :;
Building Permit Issue Date:
l...J.//.
4-8 -2£)1(,
DATE
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