HomeMy WebLinkAboutApplicationCommunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.ga rfi el d -co unty.co m
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
ESB New Installation 7 0 Alteration
0 Repair
WASTE TYPE
Or Dwelling
0 Transient Use -' 0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES _
Property Owner: curdL .o rl h3P. d Phone: (47' ) 977-15.1a,
CE[wood Acy-s, CO gi(po2_
Mailing Address: ?.D • t7k 3 Z LP
Contractor: (7rr7 i P F-
Mailing Address: 5, Ja
Phone: (i 7D)n7-75-4/6
20 �[ 70 - l�� J g-- 4/11
kfiyvoad .:pis', Co 0/66"2--
Engineer:
I6o2
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: itier 12* -3---C477-77770
/enw - fI) i Hilo/
Assessor's Parcel Number:71' ' `C ee-4'd - p / -Sub.
Building or Service Type: Sin* f' 4r47i! )
Distance to Nearest Community Sewer System:
Lot Block
#Bedrooms: i- Garbage Grinder )45-
N
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Lor Septic Tank 0 Aeration Plant 0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use 0 Recycling
❑ Chemical Toilet 0 Other
0 Pit Privy 0 Incineration Toilet
Ground Conditions
Depth to 1" Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit
0 Underground Dispersal 0 Above Ground Dispersal
Evapotranspiration
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
Effluent
li'% 0 Spring 0 Stream or Creek��((❑ Cistern
"Community Water System Name I�,,je5+kD-41-- 6AKFR WAT Q
Will Effluent be discharged directly into waters of the State? 0 Yes jd'Ng
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
h ve provided the ` r uired infor tion which is correct a • : ccurate to the best of my knowledge.
Vue64.14 v1' - ' 4, .•� '
4ItD— ycpc.I�� f 7
Property
Owner Print and Sig
Date
il- , tJ i+itA-C-
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Building Permit
BLDG DIV:
Perk Fee: i
Septic Permit:,
crpr- f l
.4111,
rr `
Po- 23 cc qIs Itm-
1
Total Fees:
Issue Da
Fees Paid:
23
Balance Due:
4/16120 17
DATE