HomeMy WebLinkAboutApplicationGarfield County j
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970)945-8212
www.earfield-county,com
TYPE OF CONSTRUCTION
New Installation
WASTE 'TYPE
ONSITE WASTEWATER
SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
0 Repair
Dwelling 0 Transient Use
0 Other Describe
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner} ' .''� Ll 4 Phone:
Mailing Address:45V p` 1 y+n
Contractor: Phone: ( )
Mailing Address:
Engineer: Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:
enrft)t,o 7)r-i'Le
Assessor's Parcel Number: t�,0. .,1kr, ► -ub, .c1640/t4,n" $4 . Lot % Block
Building or Service Type: ec4 (IP `k'iG 1 _ #Bedrooms: 1-1 Garbage Grinder
Distance to Nearest Community Sewer System: ?----SAe
Was an effort made to connect to the Community Sewer System: f a
Type of OWTS pticTank I 0 Aeration Plant 0 Vault J 0 Vault Privy
❑ Recycling, Potable Use ❑ Recycling 0 Pit Privy
❑ Chemical Toilet [ 0 Other
0 Composting Toilet
❑ Incineration Toilet
Ground Conditions
Depth to 14 Ground water table
Final Disposal by
Percent Ground Slope
Absorption trench, Bed or Pit 1 0 Underground Dispersal I 0 Above Ground Dispersal
❑ Evapotranspiration I 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type it WeII [ spring 1 0 Stream or Creek 0 Cistern
Community Water System` Name
Effluent Will Effluent be discharged directly into waters of the State?
❑ Yes
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditions upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and fumished 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. 1
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
have provided the required information which is correct and accurate to the best of my knowledge.
TV -64N D'AX X -ed -41÷/
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Pe it Fee:
Ja.�
Perk Fee:
CNG
Total Fees:
1v\-3 CZ
Fees Paid:
Sig •00
Building Permit
Septic Permit:
issue ate:
Balapce Due: _
BLDG DIV:
14/4017.01 r
APPROVAL
I DATE
6- 0.
ec 143,00