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Garfield County
Community Development Department
108 8th Street, Suite j -F.-
Glenwood Springs, CO 81601
(970) 945-8212 ' L i
www.garfield-countv.com
ONSITE WASTEWATER
SYSTEM
(OWTS)
PERMIT APPLICATION
TREATMENT
TYPE OF CONSTRUCTION
El New Installation Alteration ❑ Repair
WASTE TYPE;-_
❑ Dwelling I 0 Transient Use Comm./Industrial 0 Non -Domestic
❑ Other Describe
X " o M E `t-1 G ,C VJACSE.-
INVOLVED PARTIES.
Property Owner:
Mailing Address: % 'DAV 1 D DabSv k) go, 1:30k i c2L{8 GamAiotb 5F65 i Co greo
Contractor: CAV Uhf . 1 �,. Phone: ( ¶¶70' ) ?(.3—
Mailing Address: PO, 60X 1151 CAR6oN DAL ) Cr() a gI G2 V
Engineer: PAilti(< 'PETS ALL sE.RviCE Phone: ( q70 )
Mailing Address: 33 FooR, Wl E L. VRI'/E Rb. CIg$'0fNIDRLE l CJ , 91423
PROJECT NAnME AN. LiCATISN taAu ,'cwiveg7,5
Job Address: hk". � , PA OUT. 43F Le oo y 't'c
Assessor's Parcel Number: Sub. V I.1 RAO) ?VA Lot
Block
Building or Service Type: TX)$E uJ /6 , #Bedrooms: r--_ Garbage Grinder
Distance to Nearest Community Sewer System: 1 L -E-5
Was an effort made to connect to the Community Sewer System: -- Neer Lo GAL
Type of OWTS
Septic Tank 1 ❑ Aeration Plant ❑
❑ Recycling, Potable Use 0 Recycling
' ❑ Chemical Toilet 0 Other
Vault
❑ Vault Privy J ❑ Composting Toilet
❑ Pit Privy 0 Incineration Toilet
Ground Conditions Depth to e` Ground water table L Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit ; ❑ Underground Dispersal 0 Above Ground Dispersal
0 Evapotranspiration 1 0 Wastewater Pond ' 0 Sand Filter
❑ Other
Water Source & Type Well 0 Spring 0 Stream or Creek 1 0 Cistern.
0 Community Water System Name c ,
Effluent Will Effluent be discharged directly Into waters of the State? 0 Yes
, AEiti m i ,. 1r }'Tri .....5 Fu FjP-'
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.
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.
RAND FAQ< OWker{5-10`..50e. r
hereby acknowledge that 1 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.
Property Owner Print and Sign
5-4-2016
Date
[Ht�hSE.Ol" IIY
Special Conditions: /j7 -1L-4 r ,ilia .s
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44 -,-I P 7e) '
. , t4iIn-FR,I
.4 CO.
rairr-a.
u Y , ...riz E:&o_t,
P m`�it Fee O0
Perk Fee:
Total Feess:
Fees Paid:
Building Permit
1) / R.
Septic Permit:
Issue ate:
Balance D�uJ
BLDG DIV: t
r
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� Tp -2040
APPROV.
DATE
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