HomeMy WebLinkAboutApplicationGarfield County
q;\ Ll Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYIPJ OF CONSTRUCTION
septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
Composting Toilet
0 Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
New Installation
•
Alteration
•
Repair
WASTE TYPE
` Percent Ground Slope
r
SI Absorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal
El Dwelling • Transient Use
} 0 Wastewater Pond Sand Filter
ii
• Comm./Industrial
❑ Other
• Non -Domestic
Water Source & Type
0 Well
0 Spring
0 Stream or Creek I 0 Cistern
• Other Describe
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes No
INVOLVED PARTIES
Property Owner: 156 Orchard Creek Ranch LLC Phone: ( 970 )-2 L6-0779
Mailing Address: 832 Canyon Creek Drive, Glenwood Springs. Co 81601
Email Address: ncreekr@gmail_com
Contractor: Doug Hayes
Mailing Address: 1002 Blake Ave, Glenwood springs, Co 81601
Email Address: dhayesconstructionc gmail.com
Phone: ( 970- )618-6525
Engineer: Derir Walttrc Phone: ( 970 )945-5252
Mailing Address: 923 Cooper Ave, Glenwood Springs, Co 81601
Email Address: deric(bu-inc.Com
PROJECT NAME AND LOCATION
Job Address: 156 G42�.P►'t1) .b f37 G IAJa4 e C D 1140
Assessor's Parcel Number: 21850521431 Sub. N/A Lot Block
Building or Service Type: Single Family residential #Bedrooms: 3 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System: N/A
Was an effort made to connect to the Community Sewer System: N/A
Type of OWTS
septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
Composting Toilet
0 Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
0 Chemical Toilet
0 Other
_
Ground Conditions
Depth tor, Ground water table
` Percent Ground Slope
Final Disposal by
SI Absorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal
0 Evapotranspiration
} 0 Wastewater Pond Sand Filter
ii
❑ Other
Water Source & Type
0 Well
0 Spring
0 Stream or Creek I 0 Cistern
❑ Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes No
r
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.
Pro wner Print and Sign
�- Zy-f,
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
3-
I2
Perk Fee:
�•
NC�
Total Fees:
' 2 3 -
2 Fees Paid:
I 3_
Building Permit
,u - 4T 3
Septic Permit:
se -yr -All -14
Issue Date:
Irl
Ii
Balance Dur
BUILDING/ PLANNING DIVISION:
.1j 27
17
Signed Approval
Date
. 2_, .00) C21 10(3] n-