HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, C 042016
(970) 945-821
www.earfield-countv.com
[TYPE OF CONSTRUCTION
SI New Installation
WASTE TYPE
II Dwelling 0 Transient Use
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIE
Ir Property Owner: �AS644.464
Y Phone: (q7D ) 379 -?'3
Mailing Address: 113Mc5ez 74.ne, Gq,2iad"c t, CO 8/623
Contractor: finefrie (7tJ64eR (t/ASdn A�f/t� Phone: (q,6 )179 -s) /3
Mailing Address: yZ 84-45t4. 721nd (446tllot/r/i (ci 9a,, 23
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 0030 $6pz73 /41 i 0411.60,104-1:.(016 6 / 62 ?
Assessor's Parcel Number: 7393 -vtt'i5 -O/i, Sub. C/1105 fie
Block
Building or Service Type: RLS id in
Distance to Nearest Community Sewer System: 2
#Bedrooms: '--t' Garbage Grinder
Was an effort made to connect to the Community Sewer System:
Type of OWTS
y1e S
Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Compos-tingToilet
▪ Recycling, Potable Use 0 Recyding 0 Pit Privy 0 indneration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to 1" Ground water table Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O other
W- ater Source & Type 48 Well 0 Spring 0 Stream or Creek 0 Cistern
1
O Community Water System Name
E- ffluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 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 acknowledge that I have read and understand the Notice and Certification above as well as
hav providedythe regyjr d information which is correct and accurate to the best of my knowledge.
04
P perty Owner Prign
el 17,0fC
Date
OFFICIAL USE ONLY
Spedal Conditions:
Permit Fee: da
4S/R12 ,
Perk Fee:
l it
To al Fees:
,293. °
Felts Paid: CO
'0278,
Building Permit
1�E- I -kW
S = . tic Pe t:
a • - ?,1
Issue Date:
L1141�i7
Balance �te:
5`
�
BLDG DIV:-.t.,r..�
.0 21-20
APPROVAL / DATE
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