HomeMy WebLinkAboutApplicationGarfield County
{rr.fi~~nity Development Department
{i x~ '\:' 108 gth Street, Suite 401
°"d"'C Cl'J Glenwood Springs, CO 81601
,,,.\'.J \) t~\~ (970) 945-8212
~~\. i \ ~'WW .g arfield-coun tv .com
rQv• <"
.--\..\) v ac\'t .-<.\..-: ..-\•~\ '
':V~~OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
/
Ii New In stallation I Ii Al terat ion I Ila' Repai r
WASTE TYPE
D Dwell i ng I D Transient Use ! Ii Comm./lndustrial I D Non-Domestic
D Other Describe
Property Owner: -'-~' --4-~"'----'-'t9....l~ }
Mailing Address: -~_,_.l--,::.::...._.J-.1.....!-'~4-~-+4-l".:.....:::=---l~-!..L~..1.1...L,~~~........,=-.;~O 2/ ~:Z,. -Contractor: _.._._..~---~=-'--l-....1-J~""-1,..4+-1..------Phone: (, ___ . _______ _
Mailing Address: _________________________ ...___._..i....z~..:.-~
Engineer: ____________________ Phone:( ___ --------
Mailing Address: ______________________________ _
Job Address: -~-1-~~--1r--i4-L.L..-=i'-_..;t...._,_~.::....:-:.___..=~.....;..'--z...L;~~~'-'-~====---t
Assessor's Parcel Number:~ 0
Building or Service Type: ~ \U'{\(). #Bedrooms: .5 Garbage Grinder_
Distance to Nearest Community Sewer syhi:m: ___________________ _
Was an effort made to con ct to the Community Sewer System:-------------
TypeofOWTS D Aeration Plant D Vault D Vault Privy Cl Composting Toilet
Cl Recycling, Potable Use D Recycling Cl Incineration Toilet
Cl Chemical Tollet
Ground Conditions Depth to 1 Ground water table-----Percent Ground Slope ------
Final Disposal by D Absorption trench, Bed or Pit D Underground Dispersal Cl Above Ground Dispersal
D Evapotranspiration D Wastewater Pond Cl Sand Filter
Cl Other ________________________ _
Water Source & Type Cl Well Cl Spring Cl Stream or Creek D Cistern
Cl Community Water System Name _________________ _
Effluent Will Effluent be discharged directly Into waters of the State? Cl Yes D 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 cond itions as deemed
necessary to insure compliance w i th 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 falsificat i on 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
have provided the required information which is correct and accurate to the best of my knowledge.
7 Ja o (I~ ~ N q !YI c._Lea u smiMt (
Property Owner Print and Sign { Date
OFFICIAL USE ONLY
Special Conditions:
Total Fees : OO
$f.:5,
Perk Fee: Fees Paid: (!){)
:/J ?-Q. Pe~tFee : OD
-Building Permit Septic Permit: Issue Date :
-'i~~ 7.
Balance Du ~
7 . 2)-lk,
I
DATE