HomeMy WebLinkAboutApplicationGarfield County
~1 £~ \.I\ 1~ Community Development Department
'i:l -· ·· 108 8 1h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYpt OF CONSTRUCTION
121' New Installation I D Alteration
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
l D Re pair
¥oTETYPE
Dwellin g I D Transient Use I D Comm ./Ind ustria I I D Non-Domestic
D Other Describe
INVOLVED PARTIES
"5 rct -5 -~ ":f .J.-. Property Owner: ~ lA ':>ftN £ H-nl?AI Phone: (__g_'.:W_)
Mailing Address: G,5'1<2 Hw~ <2d-G.w~J Co ~L~OI
Email Address: a+o+o p v l6 s @. bd-MG\·, \ . <'.'.D «\
Contractor: £:lWiVc~ . Phone:( __ )
Mailing Address :
Email Address:
Engineer: Ou L-A t"\~ l lAP.12 fu.. Phone: (_g}Q_) "3 OCf·-~.") ~ 4
Mailing Address : °33 foul< WH. tsL {Ja_ i?IJ LAR.601\/tlAlE l.6 ~11'oJ."3
Email Address:
PROJECT NAME AND LOCATION
Job Address: -c;-~<2 Hw'I i&:r Gw'S 1 L<l ~I loO I
Assessor's Parcel Number: 0 ( -'1-b-""[ Sub . Lot ~ Block --
Building or Service Type: #Bedrooms: a Garbage Disposal(Y/N)~
Distance to Nearest Community Sewer System: tVI A
Was an effort made to connect to the Community Sewer System: tV {A
/
TypeofOWTS Ill Septic Tank I a Aeration Plant I a Vault I a Vault Privy I D Composting Toilet
0 Recycling, Potable Use D Recycling I a Pit Privy I 0 Incineration Toilet
0 Chemical Toilet 0 Other
Ground Conditions Depth to 1'1 Ground water table J Percent Ground Slope
,;
Final Disposal by !!' Absorption trench, Bed or Pit I a Underground Dispersal I 0 Above Ground Dispersal
0 Evapotranspiration a Wastewater Pond I 0 Sand Filter
0 Other
Water Source & Type -rien I a Spring l 0 Stream or Creek l D Cistern
--D Community Water System Name _,,
Effluent Will Effluent be discharged directly into waters of the State? D Yes ID' No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be requirPn hy thP. 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 loca l
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 resu lt 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-I 9 -17
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
\·~'1·-Perk Fee: f _ fNl7 Total Fees: I 1.?;·-Fees Paid:
Issue Date: Balance Due : .
Signed Approval
