HomeMy WebLinkAboutApplicationLC Garfield County
Community Development Department
108 8t" Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
NOV 0 4 2015
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
5r New Installation
0 Alteration
•
Repair
WASTE TYPE
RI' Dwelling 1
•
Transient Use
0 Comm./Industrial
1
• Non -Domestic
• Other Describe
1. INVOLVED PARTIES __
Property Owner:—5,kno■.a_ t t.,,f L .�t.1 L, Phone: (333 _) $r,,.! .,/ f
Mailing Address: _SCJ _ i_/th ,i _ks +le L, El
Contractor: 5rj
Phone:(
Mailing Address:
Engineer: Phone: (
Mailing Address:
ROJECT NAME AND LOCATION
Job Address: e) r /i Veto Czti fIE'1 'ill_
Assessor's Parcel Number: Sub.
Building or Service Type:
Lot Block
#Bedrooms: 3 Garbage Grinder
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS R Septic Tank 0 Aeration Plant
r0 Recycling, Potable Use
0 Chemical Toilet
0 Vault
0 Vault Privy 0 Composting Toilet '
O Recycling 0 Pit Privy 0 Incineration Toilet
0 Other
Ground Conditions Depth to 1'r Ground water table Percent Ground Slope
Final Disposal by
13 Absorption trench. Bed or Pit 0 Underground Dispersal
O Evapotranspiration
❑ Other
Well
0 Above Ground Dispersal
O Wastewater Pond
0 Sand Filter
Water Source & Type ❑spring lb Stream or Creek 1 0 Cistern
I
O Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 0 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 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_
hereby acknowledge that 1 have read and understand the Notice and Certification above as well as
have provi4ed the reqpired information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
//- 74.
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
i 2-3 -
Perk Fee:
I S) —
Total Fees:
-13 —
Fees Paid:
;---+-3 —
Building Permit
Ba -t - (-11-1g(f5pc-
Septic Permit:
14,-19C
Issue Date:
12-I 2.O(a
Balance Due:
BLDG DIV: '/
-; ta. I- 41/1
APPROVAL 41 DATE
. 00) Niko, 1 1LO(So