HomeMy WebLinkAboutApplicationfig.. Community Development Department
` D1.0 108 8th Street, Suite 401
Glenwood Springs, CO 81601
AU5 '31i 17 (970) 945-8212
• ,;p,..:3_,:1;1.40.0voii4 . www.garfield-county.com
tiGarfield County
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Property Owner: . t A 1 J. ! �� Phone: (• } 7
) d. 7 t -1,C.,24
l:,
Mailing Address: !j l2 4v $ k 0r. a�et.) 6,<,./h- (() 864?
I•, New Installation
•
Alteration
•
Repair
WASTE TYPE
PROJECT NAME AND LOCATION
Job Address: 1,1c 6, 1 c.,--7 Pel (4 5 ! (1L-- ce-D 6 j in S c7--
1:::2
Assessor's Parcel Number: I ro r- 1(f Sub. f Lot / t Block
l
Building or Service Type: DIi_ir 11r -L. #Bedrooms: Garbage Grinder _
tDwelling • Transient Use
Was an effort made to connect to the Community Sewer System: IA()
• Comm./Industrial
Type of OWTS
• Non -Domestic
• Other Describe
I 0 Vault
0 Vault Privy !
0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
INVOLVED PARTIES
Property Owner: . t A 1 J. ! �� Phone: (• } 7
) d. 7 t -1,C.,24
l:,
Mailing Address: !j l2 4v $ k 0r. a�et.) 6,<,./h- (() 864?
Contractor: 111 C' c. o Phone: ((2)
Mailing Address: / 7 4 rf. a 4 �:sc CO 7 r C,
Engineer: fl - f f ') N--Gt..[ Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 1,1c 6, 1 c.,--7 Pel (4 5 ! (1L-- ce-D 6 j in S c7--
1:::2
Assessor's Parcel Number: I ro r- 1(f Sub. f Lot / t Block
l
Building or Service Type: DIi_ir 11r -L. #Bedrooms: Garbage Grinder _
Distance to Nearest Community Sewer System: II.
Was an effort made to connect to the Community Sewer System: IA()
Type of OWTS
ii9tSeptic Tank
0 Aeration Plant
I 0 Vault
0 Vault Privy !
0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table (10 04' 'r
Percent Ground Slope
Final Disposal by
0 Absorption trench, Bed or Pit
0 Underground Dispersal
I 0 Above Ground Dispersal
❑ Evapotranspiration [ ❑ Wastewater Pond I 0 Sand Filter
❑ Other
Water Source & Type
Ilk _,WeII
0 Spring
0 Stream or Creek
r
0 Cistern
tl
ommunity Water System Name t /44._r �
c. �G
Effluent
Will Effluent be discharged directly into waters of the State? 0 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 req ired information which is correct and accurate to the best of my knowledge.
roperty Owner Print and Sign
Date
OFFICIAL USE ONLYIna
SpecialCvnd'stions: 12Wiruk til
Nnot u atct ` y \_ ,y Vw fS.
Per it e: Q�
Per) kib•
Tatal_F .C°
Fees
Building Permit
SI "Vii -
Septic Permit:
s 10.4
Issue Date:
Ib/l2-12
Balance Due:
Sie .
BLDG DIV:
I
WI( ( / 7-0/7
APPROVAL
DATE
Pasid 17,1„ /an-