HomeMy WebLinkAboutApplicationGen -field county
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.ga rfiel d -co unty.com
TYPE OF CONSTRUCTION
Zr New Installation
WASTE TYPE
)21" Dwelling
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
❑ Repair
0 Transient Use i ❑ Comm./Industrial ❑ Non -Domestic
INVOLVED PARTIES
Property Owner:. ErPratZ4(N 3Ab-AoY L,'J,%/ Phone: (,)5 f 1/0
Mailing Address: ,'Wo *x D.9 -z61— L'.4. ''s Vol 6) p D 2/'S'
Email Address: .TXr ic"1- 0 t/M/1" -^he r
Contractor: Dr.JN
Mailing Address:
Email Address:
Phone:
Engineer: , -''taw/` - 5 €.." c_
Phone: ono ) 50# er
Mailing Address: 3 Pi2verl- 4e. -0. LA /o 8�G Z3
Q /L S<C&/!J SL, i71
Email Address:
Go.✓t-
PROJECT NAME AND LOCATION
Job Address: T Cid- /J7 g1//4
Assessor's Parcel Number: 23 f49( -P" he Sub. /fte`
Building or Service Type: iik-5/At, —
Lot Block
#Bedrooms: Garbage Disposal ± Distance tj
Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: N//4"
Type of OWTS
Ground Conditions
Final Disposal by
IT -Septic Tank I 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
0 Recycling, Potable Use � 0 Recycling 0 Pit Privy
O Chemical Toilet 0 Other
0 Incineration Toilet
Depth to 1st Ground water table
Percent Ground Slope
0 Absorption trench, Bed or Pit I 0 Underground Dispersal 0
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type $Well 0 Spring 0 Stream or Creek
Effluent
Above Ground Dispersal
0 Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes jit 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. 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.
J.29-/444,ft,-- ieziAJA(44,/--
Property Owner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: co
Building Permit
Date
)114-#4-4-411 5:e -T ACCPCS rg001
Total Fees:
rr�� Fees Paid:
n�77
Perk Fee:
Septic Permit:�j y
3.i moi'' 1 ;
BUILDING/ PLANNING DIVISION:
Signed Ap
Issue Dat: ` 1
Balance Due:�
Z
3-3b-20/7
Date