HomeMy WebLinkAboutApplicationCpmmunity Development Department
6151° 108 8th Street, Suite 401
ASG 1 Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-countv.com
TYPE OF CONSTRUCTION
, New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
WASTE TYPE
Dwelling
0 Other Describe
0 Transient Use
INVOLVED PARTIES
Property Owner:
Mailing Address: 7
Comm./Industrial
Mailing ddress:
Enginee : c u c\ C'ISk-eI'c1
Mailing ddr4ss: �i f otir
PROJECT NAME AND LOCATI
Job Address:
Assessor's Parcel Nu
Building or Service Type
Distance to Nearest Com nity Sewer System:
Was an effort made to connect to the Community Sewer System:
Sub. j Lot k R Block
#Bedrooms:
Garbage Grinder _
Type of OWTS
Septic Tank
0 Aeration Plant
0 Vault
Q Vault Privy
0 Composting Toilet
O Recycling, Potable Use
❑ Recycling
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
O Other
Ground Conditions
Depth to e Ground water table
Percent Ground Slope
Final Disposal by
'Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Sand Filter
Water Source & Type
Effluent
O Other
)ell
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes
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
haprovided the required information which is correct and accurate to the best of my knowledge.
Date
A ---)Aap.,okivl,
Property Owner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
/2 .cam
Perk Fee:
Total Fees:
123.00
Fees Paid:
II .tali
Building Permit
41'3"l
Septic Permit:
rf- 431u
Issue Date:
Balance Due:
BLDG DIV:
APPROVAL DATE
rL'$ i 23.Ov