HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation —1 0 Alteration
0 Repair
WASTE TYPE
0 Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTI _ S
Proprty Owner: �1 �ti'�i►� +i1
1 Phone: ( — 'S= Sj
,1TM,a �.rr-n A6'�� C -ON L� k--3
Mailin� Ad�re s: 1r OZ.. --2Y ��,('
Contractor: , V c C-,, s•-•+t,-c�j.•\(:?
\-"A .C%
" 116-3 & (....:S 2 -r-31-72
Phone: ( 1-1)_4;,,q<- T
Mailing Address: (
0_);3N C� 0,
)
Engineer 1 ' qA L Phone: (3 ) U1 ` I K
Mailing Address: ON1 II.,,,,,,,-,(--A.-RI- V'.� U � ‘ ���
�
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number:
Building or Service Type:-
Distance to Nearest Community
Was an effort made to
.\3. -KA)=- - Sub. Lot Block
1nYt‘k\s'''\k.. V#Bedrooms: Garbage Grinder
Sewer System:
connect to the Community
Sewer System:
Type of OWTS
0 Septic Tank 0 Aeration Plant X Vault 0 Vault Privy + 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Ground water table
I Percent Ground Slope
Final Disposal by
0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration
1 0 Wastewater Pond
1 0 Sand Filter -
R Other
Water Source & Type
0 Well
0 Spring 0 Stream or Creek A Cistern
Community Water System
Will Effluent be discharged
Name -TOW r% O,r c)Qv1Crr
directly into waters of the State? 0 Yes .� No
Effluent
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. 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.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: m
75
Perk Fee: Vu--J4Total
'r,di�
Fees:
.t -,, Oa�.
Fees Paid:
06
Building Permit
Vic -Q 11
Septi ermit:
Issue Dater
2 -II I 1
Balance Due:
.
s q
I'
(13117'017
BLDG DIV:
APPROVAL DATE