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HomeMy WebLinkAboutApplicationGarfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com JAN 19 1U1G ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION Phone: (` 7t ) Piga,- q fe Property Owner: ki r't 4a r1 -es_ Mailing Address: 14 I'7 .Pi- +°, c 6 S [6 q 7 `0 New Installation 0 Alteration • Repair WASTE TYPE Engineer: Phone: ( Mailing Address: Email Address: tit Dwelling • Transient Use • Comm./Industrial PROJECT NAME AND LOCATION • Non -Domestic • Other Describe Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Was an effort made to 2. Iz7 -ZY l' -o( -001 Sub. 6,,: vit (-�a- «-. Lot 1 Block #Bedrooms: '-1 Garbage Disposal Sewer System: connect to the Community Sewer System: INVOLVED PARTIES . Phone: (` 7t ) Piga,- q fe Property Owner: ki r't 4a r1 -es_ Mailing Address: 14 I'7 .Pi- +°, c 6 S [6 q 7 _,.()3t0( ) i Email Address: ac l&rr (S C(4 wi rt 1 1 - Can 11IL , Phone: q 7 © ) g 7b Contractor: R `i' i _. u • ■ :1 Mailing Address: P A ( c v S( T Email Address: Engineer: Phone: ( Mailing Address: Email Address: n{Q 2 3 7 PROJECT NAME AND LOCATION Job Address: 310& Cgru{,k+ Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Was an effort made to 2. Iz7 -ZY l' -o( -001 Sub. 6,,: vit (-�a- «-. Lot 1 Block #Bedrooms: '-1 Garbage Disposal Sewer System: connect to the Community Sewer System: Type of OWTS ! Septic Tank 1 0 Aeration Plant 1 0 Vault l 0 Vault Privy 0 Composting Toilet ❑ Recycling, Potable Use 0 Recycling 0 Pit Privy I 0 Incineration Toilet ❑ Chemical Toilet 0 Other Ground Conditions Depth to 1" Ground water table Percent Ground Slope Final Disposal by O Absorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal O Evapotranspiration 0 Wastewater Pond 0 Sand Filter O Other _ Water Source & Type si Well [ 0 Spring 0 Stream or Creek I 0 Cistern O Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? 0 Yes gNo 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 have provided the required information which is correct and accurate to the best of my knowledge. IJen6 L.. Property Owner Print and Sign N[S -- 70( Date OFFICIAL USE ONLY Special Conditions: Permit Fee: 66 Perk ee: 00 Tot I Fees: ea 03 Fees Paid: OO Building Permit %& -45a) Septic Permit: .3M--- 435 i Issue Da e: 0 1311-i' Balan a Due:,, 0 �'lJ BLDG DIV: pa 24/0/2011 APPROVAL DATE Nam 1714,9c rtf 4150. 10 arpI ► cowl 19A - e ay) &Jnstpti c 9s/ 91-Z04 i s vrmw (plef 00+ #?)