HomeMy WebLinkAboutApplication. Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
MAY 16 7017
TYPE OF CONSTRUCTION
a New Installation
WASTE TYPE
I® Dwelling ❑ Transient Use
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
-- 1
D Alteration
INVOLVED PARTIES
Property Owner: .61.-, P_ Kr'
0 Comm./Industrial
Mailing Address:002 104?9e rz zi
Contractor: 01 l kc... � Pe ,1 i0-
o•
Mailing Address: d' )� d
D Repair
0 Non -Domestic
Phone: (cr7 O) r; 2 19.
6114 a.0
Phone: (4110 ) c'"T 66 — t90
. a
Engineer: Phone:
Mailing Address:
PROJECT NAME AND LOCATION
Job Address:16'2,0 f`a . r'4 re. GI its
Assessor's Parcel Number: G/0 / Z 3a��' . Z Sub. Lot Block
Building or Service Type: i' !. fit; (p Pwe-I(/ -1 #Bedrooms: 1' Garbage Grinder Ne)
Distance to Nearest Community Sewer System: ,4/ /4
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
•
E Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet 1
0 Recycling ❑ Pit Privy i 0 Incineration Toilet
O Recycling, Potable Use
O Chemical Toilet
0 Other
Depth to 15` Ground water table 7C Percent Ground Slope 6-
D Absorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal
❑ Evapotranspiration
❑ Other
0 Wastewater Pond 0 Sand Filter
11=V" WeII 0 Spring
0 Stream or Creek 0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yeslo
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.
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
Property Owner Print and Sign
d accurate to the best of my knowledge.
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I /%' —
Perk Fee:
�CO --
Total Fees:
—
12s1 -
Fees Paid:
�%
b- —
Building Permit
RL, 1-3
Septic Permit:
sc T7 - LI 1-31-
Issue Dat :
l r2- wlTh-
Balance Due:
BLDG DIV: �/" fA l'4° 17
APPROVAL DATE
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