HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
SEP 2 0 1016 (970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
~~:1~~:i~i~~cri_o_N ___ ____._D_~A~lt_e~ra_t_io_n ______ I ""'" .. ---_;.D_---_R_-~_,__P~-i~-=----===1
WASTE TYPE -----1
D Other Describe -----------------------------
I Property Owner: .J.4-..LLLJ4-!.~"-J.....Ll.JL.l.L;'-J--=--'-"~~:J......-t....<'::j..J.:.~~
Mailing Address: -.+.a.u..t-.ii=.iJ.U,l~~""'.r.:....t.~...a:;µ....;:,~~.!...1.t!;.Q...1.l<.::~..L...J.~-1-.c..L.-'"'"'----'c.u.i!....J.:.L.!.:':I---
~ · contractor: --'-...Jq..J"""-~-...u::z::.L...i.!J._;2. _______ Phone: ( tf?V > 1/2 -W,sY,
Mailing Address: .3.fS7> /i;Mal!a-De .1 L+lze /h,//'M"t<. @:) 1 ,A-2... i"~ C/tJ </
Engineer: --'~~t"''.ft:-1----------------Phone:(.___ _ _, _______ _
Mailing Address:-------------------------------
PROJECT NAME ANO LOCATION
Job Address: =m D >-:-fll ..ethi't~'tJu.J--"-1>~12-.-1 3 TB7a Klh.52
Assessor's Parcel Number: ~1 1 9/JS.3();,{0 J.3 Sub.Su JU /J1ettdiu> EdJ-e:g ot 2·-3 Block
Building or Service Type: $ pg #Bedrooms: 3 Garbage Grinder _L
I Distance to Nearest Community Sewer System: _ ___.AJ'=i-/.....cA:~---------------
Was an effort made to connect to the Community Sewer System: --.!.:AJ'4-/~&:'---------' TypeofOWTS ~eptlc Tank j D Aeration Plant j D Vault ! D Vault Privy I D Composting Toilet
i0 Recycling, Potable Use 0 Recycling
I
D PitPrivy I D Incineration Toilet
0 Chemical Toilet D Other
Ground Conditions Depth to 1st Ground water table j Percent Ground Slope
Final Disposal by D Absorption trench, Bed or Pit I D Underground Dispersal I D Above Ground Dispersal
D Evapotranspiration D Wastewater Pond I D Sand Filter
D Other
Water Source & Type 0 Well [ D Spring I D Stream or Creek j D Cistern
' I ?t-Community Water System Name S"'"1 l~eAda{L) Es.~ s
Effluent Will Effluent be discharged directly into waters of the State? D Yes 0 No
l
CER'TIFICA TION
Applicant acknowledges that the compreteness of the appncatfon 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, informatic:in 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 i n the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury 1 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 rrect and accurate to the best of my knowledge.
Date
OFFICl·AL l:JSE ONbV
Special Conditions:
Perk Fee:
lfl>. 61>
Total Fees:
-z.., 1-3. 6-0 Fees Pa~-:} '3. 61) Permit Fee:
-z,3,6b
Septic Permit:' Issue-Date: · Balanre Due~¢
(D-/Jr&/(a
DATE