HomeMy WebLinkAboutApplicationGarfield County
p�R Zaommunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfieid-county.com
TYPE OF CONSTRUCTION
)1( New Installation
WASTE TYPE
OUAIDING
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
® Alteration
® Dwelling 0 Transient Use)Ar.Comm./Industrial
❑ Other Describe
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: "tel N (J-141 < ' Urliz t
Mailing Address: 0) --re, G f2 7
Phone: 0,70 J 7 7 <-, : ]
C 616 CD
Contractor: Her. ,c Otm4etrt.
'TN s",•N
Phone: (9 71) ) 01 E37
Mailing Address:
Engineer: N/A.
Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: OXS-9 Ott el Eu
C -C7 G ! as -o
Assessor's Parcel Number: a 1 -7 -71;4•b°1:59 -tub. Sub. Lot Block
Building or Service Type: P.a.- SloE uct #Bedrooms: 4 Garbage Grinder tdo
Distance to Nearest Community Sewer System: 11 &IIL-SS
Was an effort made to connect to the Community Sewer System:
Nd
Type of OWTS in Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
❑ Recycling, Potable Use 0 Recycling
❑ Chemical Toilet 0 Other
0 Composting Toilet
0 Pit Privy 0 Incineration Toilet
Ground Conditions Depth to 11r Ground water table
Percent Ground Slope 1
Final Disposal by II Absorption trench, Bed or Pit 13 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type III 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 i No
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 acknow)edge,that I have read and understand the Notice and Certification above as well as
7have provide a requir d information which is correct and accurate to the best of my knowledge.
Print and
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Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees:
Fees Paid:
Building Permit
Septic Permit:
Issue te: I
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Balance Due:
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