HomeMy WebLinkAboutApplicationRV( •
MAY 12110
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
Dwelling 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: L;Ili, r Ev� Phone: 7OJ 3 7,, r- CY/cf.
Mailing Address: i❑p . lye( �pi ti ❑! - reit r d' le f CO 3
Email Address: Cd__l'#frr l0. 1 - 020AContractor: C,I4 -'vat , adr►1144-140++ Phone: (170 ) ?19 = 9J13
Mailing Address: P. 0 k,,,C.317 £wb' (1IIApc , A) R('i
Email Address: %H b A i CCA q rt • Corti
Engineer: 1t I} C Writil eol, mete i Phone: (f� /f� - h i,
Mailing Address: 1 �7
hail hot if 1D( lemooki Epr , r s (0 if 40/
l
Email Address: �rtiA a 1,c C • cam 1-1W H« 6 • Cd Mi
PROJECT Job Address: fGlO i irk{ r :►rte fir, I co ef (nf 3
Assessor's Parcel Number:. / 744 rgLSub. kbe rM) Lek . i4., .e Lot S. _ Block
Building or Service Type: ?..e,i j A1 #Bedrooms: gGarbage Disposal / Distance tt
Nearest Community Sewer System: Gil1ftansiGj Ci+1 - m; I[S
Was an effort made to connect to the Community Sewer System: Ma
Type of OWTS
)6� Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use 0 Recycling 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 0 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond t 0 Sand Filter
O Other
Water Source & Type
Effluent
Well 0 Spring
0 Stream or Creek 0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes ❑ No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may he 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
ha - provided the required inf• r - ,-on hich is correct and accurate to the best of my knowledge.
!217
Ya1
Property Owner Print and Si; n
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Building Permit
Perk Fee:
Septic Permit:
Sr" L
BUILDING/ PLANNING DIVISION:
? o . k 0/7.01)) J O D7 S
Issue Date:
ti) 41
Signed Approval
�tT
Fees Paid: ,
Balance Due:0
a4MN7
Date