HomeMy WebLinkAboutApplication~ ~ c l\.i ~ • Community Development Department
.. D fl_'J ~ 108 gth Street, Suite 401
Glenwood Springs, CO 81601
JUL 0 6 ZUl6 (970) 945-8212
GAr.ritLI 1 L.Ud IJ 1 www .garfield-countv.com
''\'UNIT Y
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 N ~~tion [D Alteratio_n _____ _ • Repair
WASTE TYPE
B Dwelling 0 Transient Use }_Q_ Comm./lndu ~trial __ .__0_ Non-Domestic
D Other Describe -------------------------------
I. INVOLVED PARTIES \ ~
Property Owne-;;-aQ<Q Q -1-la l Phone: ( '{17/. J . Jf1-r:J -(;7?J2 ~
~MaiU~A~~~=~O~Z-~~~~~-~~~-l~:u~n-~-~~d~-------=~~-~~~~-==~-
Contractor: --------------------Phone:( ___ --------
Mailing Address: _______________________________ _
Assessor's Parcel Number: _______ Sub . _________ lot ___ Block
Building or Service Type: -----------#Bedrooms: 3 Garbage Grinder .J_
Distance to Nearest Community Sewer System:
I Was an effort made to connect to the Community Sewer System:
Type of OWTS • Septic Tank I D Aeration Plant I D Vault l D Vault Privy i a Composting Toilet
a Rec.ycllng, Potable Use r a Recycling I . c:f Plt Prl~ Incineration Toilet . -
0 Chemical Toilet a Other
Ground Conditions Depth to l n Ground water table I Percent Ground Slope
Final Disposal by 1 • Absorption trench, Bed or Pit ' 0 Underground Dispersal I 0 Above Ground Dispersal
I
1 0 Evapotransplratlon I a Wastewater Pond 0 Sand Filter
-0 Other
,____ -------I Water Source & Type I Well j D Spring 0 Stream or Creek-TO' Cistern
D Community Water System Nam_e __ ---
Effluent Will Effluent be discharged directly into waters of the State? D Yes CNo
L__ ----
..
f CERTIFICATION
Appl iCaiit"ack nowledges 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 ba sed upon said application and legal action for perjury
as provided by law. ___ _J
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.
ao.rol\ t\1 HC\11 L M ~ 1-', /(o
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
P~lt Fee: OO 7. .
Perk Fee: Total Fees: ,, oo Fees Paid: 00 :/;-'*5.
Balan-51 Dueb lJ
7 -b 20/l-,
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DATE