HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 9th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945·8212
www.garfield-county.com
JYPE OF CONSTRUCTION
Cl New Installation I D Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I a Repa ir
IJI Dwelling 1 D Transient Use I D Comm./lndustrial l D Non -Dom e stic
I D Other Describe
INVOLVED PARTIES -1. . _i_L ~
Property Owner: /1lv/$E tfv.'-r;-.l-~.6--"--------P-h-one:f 7-t ) ffJ ,... 0 r 7;t:J
Mailing Address: t J 1 //!lo Y'~.J/ /Jr'
21 ~ II 'if Contractor: I r1r S"J/f Phone: ( 9]L' ) ~ ~
wt!.
Malling Address: 1:-59-//;J/c""'if ,0 .. -
Engineer: Phone: ( )
Malling Address:
PROJECT NAME ANO LOCATION
Job Address: -r·ri r J
Assessor's Parcel Number: 239128300229 Sub .---------Lot Block
Building or Service Type: _a_~;..;...._!_6_11..::;·, ______ #Bedrooms: __ .!;., ___ Garbage Grinder_
Distance to Nearest Community Sewer System: __ ,_/~O~m:..;..;.'..;;;~;;...;.., --------~----
Was an effort made to connect to the Community Sewer System: _......,;1_//._.0...._ ________ _
TypeofOWTS · 9[ Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy a Composting Tollet
0 Recycling, Potable Use 0 Recycling f 0 PltPrlvy j D Incineration Toilet
D Chemical Toilet D Other
I
Ground Conditions j Depth to 1"" Ground water table h.n /-I I-j Percent Ground Slope
Final Disposal by lJi"' Absorption trench, Bed or Pit · 1 0 Underground Dispersal 0 Above Ground Dispersal ---I
0 Evapotransplratlon I a Wastewater Pond I 0 Sand Fiiter
I Water Source & Type
D Other _______________________ _
~Well 0 Spring 0 Stream or Creek 0 Cistern
r-::-:: -------D Community Water System Name _____________ =-===J
e ffluent Wiii Effluent be d ischarged directly Into waters of the St ate? 0 Yes -~
I CERTIFICATION
'AiiPlicant acknowtedges 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 I ~~~lication or revocation of any permit granted based upon said application and legal action for perjury I
L rovided by law .
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
o ded the require Information which Is correct and accurate to the best of my knowledge.
~-;J;, &f/J p;f//1~ 384
;>
Property Owner Print and Sign Date
OFFICIAL use ONLY
Special Conditions:
Per PIM't.5, pttedes1q11ed, eugwteer fl u1red..
Fees Paid : <!$;;:;_~. oo Total Fees: Ci(3
$ 9-'3 .
Permit Fee:
. () 0
Building Permit Issue Date: Balance Due:
~ . 00
APPROVAL 6ATE I