HomeMy WebLinkAboutApplicationGarfield County J
Community Development Department
108 8°1i Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
a PE OF CONSTRUCTION_
la- New Installation 1 0 Alteration
0 Repair
WASTE TYPE
ta- Dwelling
0 Transient Use
0 Comm./Industrial I 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 4-Lilr4 /Volt W .ge'.�IC £
Phone: (f2n j 9G 3 --.3 �S
Mailing Address: P. de SOX /I/f f7N49Sd VO / 4 co Fib, op 3
Email Address:
Contractor: & ivz4 S PT./1)6C Phone: (Li is f 6 . 2 21,6
Mailing Address: 77, 0 &7( 3915 &WA/ A- &D 5?/ 621
Email Address: hi h S 1 fL GII Q . [.(/41-1Ua • GoM
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 0
Assessor's Parcel Number:7 3013 -,23( UO3uea Lot Block
Building or Service Type: R4. S
Distance to Nearest Community Sewer System:
#Bedrooms:
N14
3
Garbage DisposaI(Y/N) 't
Was an effort made to connect to the Community Sewer System: VA
Type of OWTS
E3 -Septic Tank 0 Aeration Plant
O Recycling, Potable Use
O Chemical Toilet
0 Vault y 0 Vault Privy 0 Composting Toilet
❑ Recycling
0 Other
0 Pit Privy 0 Incineration Toilet
Ground Conditions
Depth to 1" Ground water table
Percent Ground Slope
Final Disposal by
I$. -Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
I i
0 Sand Filter
❑ Evapotranspiration
❑ Other
0 Wastewater Pond
Water Source & Type E - well 0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 13 -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.
9.4,1,4ly01Q GtJ• SIAL /U[444 lits • �4 4ACG
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
P rmlt Fee:
lu1
Perk Fee:
41 ' 0
Total Fees:
..2'3.
Fes Paid:
1-22-.0Q
Building Permit
—
Septic Permit:
I �[
L
Issue ate•
g I 4-1/619-
Balanc Due
co
BUILDING/ PLANNING DIVISION:
1.
71127k-017
Signed Appro I
Date
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