HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 gth Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www .garfield-county.com
TYPE OF CONSTRUCTION
~ New Installation I D Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
I D Repair
S-Dwelling I D Transient Use I CJ Comm./lndustrial I D Non-Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: C. M H-fl0A, e)..
Mailing Address: G 71 2 .3. P..d_
...... Contractor: /l /'I!}. u r LJ<iyi "t-Phone: (970 -) 209 ?9 <17
MailingAddres~: 17'SO C~c,1 tr i<.r .. r RcL S,· /+ C..O 8 /{,5?.._
Engineer: l.kU'V xe--ki t1 .... ( l1vrQ [+;~'°""~ •M )
;:; v ....J
Phone: < 113-'.:i-l .,~c:fsY?~
1J1 x t/07K MailingAddress: Po f<i l'"\x-/2 58 /Jp ,r...._r;, (
PROJECT NAME AND LOCATION
JobAddress: i'IJD CA"'c' 1t [?r_,r Re St"fi co 'i:!6'5";l
Assessor's Parcel Number:J I 71~ 17 { -(.V-C.z>sub. ()(), Ho l!nr.1 !lc....rL lot I Block
Building or Service Type: Ac.Jl<l·l { t> ( ~edrooms: 71 Garbage Grinder n ...-..
Distance to Nearest Community Sewer System: ...,6.._r-_lft_,._lc.; ______________ _
Was an effort made to connect to the Community Sewer System: ..... n.:...t/"------------
Type of OWTS )S..Septic Tank l D Aeration Plant l D Vault 1 D Vault Privy I D Composting Toilet
D Recycling, Potable Use D Recycling I D Pit Privy I D Incineration Toilet -
D ChemlcalTollet D Other _______________ _
Ground Conditions I Depth to l " Ground water table j Percent Ground Slope ------
Final Disposal by Jit...Absorptlon trench, Bed or Pit Lo Underground Dispersal I a Above Ground Dispersal
lo Evapotranspiratlon -T DWast ewater Pond 1·-a Sand Filter --------
r D Other _______________________ _
Water Source & Type Jil-weri--1 D Spring _E tream or ~~eek -I .Jt Cistern
0 Community Water System Name ________________ _
Effluent Wlll Effluent be discharged directly Into waters of the State? D Yes ·---;ilt No ----
~ERTIFICATION
;pplicant ac knowledges that the completeness of the application is condltiona iUpo-n sucfifurther
mandatory and additional test and reports as may be required by the local health department to be 1 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.
OFFICIAL USE ONLY
Special Conditions:
etoornv, ~
APPROVAL
read and understand the Notice and Certification above as well as
mation which is correct and accurate to the best of my knowledge.
Date
Total Fees: t>. 00
Issue Date:
DATE