HomeMy WebLinkAboutApplicationGarfield County
R 3 0 2017
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-cou nty.co m
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation 1 0 Alteration
0 Repair
WASTE TYPE
Pr Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: /ilcA-1A�.0 \,.oc\\et Phone: (Ali) ) r_[d i/ - ) 41) 5
Mailing Address: 'Rd. fm X 63 ' Asil- 60 ay). I
,y
Email Address: 1'10g0>r Aef A. � Co r-kGaS Sr . vn e A--
rContractor:
Contractor:Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: (_ 1
Mailing Address:
Email Address:
PROJECT NAME AND
LOCATION _
L`OC ik 4 14, • Cjac'ea\CIA
Job Address:`) -"f2,
IC,
Assessor's Parcel Number:
Building or Service Type
Distance to Nearest Community
Was an effort made to
.734/394162:&
}
Sub.r&aaya'Wi kOne, Lot 360 Block
#Bedrooms: ` ) Garbage Disposal
,::\
Sewer tem:
connect to the Community
Sewer System:
Type of OWTS
gi Septic Tank 0 Aerat on Plant 0 Vault
❑ 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
Percent Ground Slope
Final Disposal by
$ Absorption trench, Bed or Pit 1 0 Underground
Dispersal 0 Above Ground Dispersal
FpSandFilter
❑ Evapotranspiration
0 Wastewater Pond
❑ Other.
Water Source & Type
0 Well
0 Spring 0 Stream or Creek 0 Cistern
0 Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 No
Applicant acknowledges that the completeness o 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.
-4 2
Property Owner Print and Sign
OFFICIAL LinlIET
Date
Special Conditions:
Permit Fee: 00
Building Permit
Perk Fee:
�r5a,e0
Septic Permit:
Issu late:
Fees Paid:
w7_(-QD
Balance D ebc
BLDG DIV:
Pie Ad
APPROVAL
r
4/20/2017
DATE