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HomeMy WebLinkAboutApplicationre Garfield Counry7 Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfleld-countv.com JUN 2 7 2017 ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION ' Ed New Installation WASTE TYPE ® Dwelling ❑ Alteration 1 ❑ Repair 0 Transient Use —1 0 Comm./Industrial 0 Non -Domestic 0 Other Describe INVOLVED PARTIES Property Owner: C.Cuie +..' '�.w� Age". -)0. Ce � .JW! Phone: (MD, ) 299 - t 3 L Mailing Address: S317t14 SV. %t• -•tiwr CAP 9saZ%Z- Email Address: Contractor: Lvaa-Skow.. T Mailing Address: 2,(.Z Co le.112J. Email Address: t .t,rry G t..000c.kp�� -�'4c . Nek Engineer:., _- ..,.w t..r Phone: (ftl'.7 SoIC- 5 z 1 Mailing Address: 3 3 V•46- .1 C# • k la ,3 Email Address: C "-el" . t3SIA• art 4 q t••• = -6.-A • C PROJECT NAME AND LOCATION Job Address: SHO $ rt CithAe.. saanal a Assessor's Parcel Number: tSRS Z3lobCa 2 Sub. � k~ RAM" Building or Service Type: w..4 #Bedrooms: Phone: (q►*! u } 4.'I -41 o y Distance to Nearest Community Sewer System: (s -� - Lot Block ' 1 Garbage DIsposal(Y/N) 1� Was an effort made to connect to the Community Sewer System: to A Type of OWTS Ground Conditions Final Disposal by Water Source & Type Effluent MI Septic Tank 0 Aeration Plant I 0 Vault I 0 Vault Privy O Recycling, Potable Use O Chemical Toilet O Recycling 0 Pit Privy Composting Toilet 0 Indneration Toilet 0 Other Depth to 1=t Ground watertae or*sr 4.,n.aenries�7GGrrk NI Absorption trench, Bed or Pit O Evapotranspiration Percent Ground Slope D Underground Dispersal O Wastewater Pond t 2. *t; © Above Ground Dispersal 0 Sand Filter O Other O Well • 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 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) _ A(SR 7/ Property Owner Print and Sign bate OFFICIAL USE ONLY Special Conditions: Permit Fee: $ +2i3 Perk Few Total Fees: Fees Paid: Building Permit Et -g -lig& Septic Permit: cC a Issue Da W e: 9-- tu271161 Balance Du : 123 — BUILDING/ PLANNING DIVISION: 03/2017 Signed Appro • Date