HomeMy WebLinkAboutApplicationon o j 1on
•'
Garfield County
Community Development Department
108 3th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www .garfleld-county.com
TYPE OF CONSTRUCTION
11 New Installation I D Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
1 D Repair
£! Dwelling I D Transient Use I D Comm./lndustrial I D Non-Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: '-<'oU\v\ H Pv' t'tMllt. "'· Phone: (.9.JO_) ~")q ~C/7~
Mailing Address: f 0 e ~'6b2. ~~tL~ ~Lfa2..I
Email Address: K \l\e V' Ywta. \I\ lW Q.~U~vlh:ia {)_ la~'"\Ae_v~ C..Q I o."1WI
Contractor: o 1)1.)"1 e . ..r Phone:(__J
Mailing Address:
Email Address:
Engineer: A l\ "5 ev \J ic_e.. Se.~\-U .. Phone: (~) ~fl "4 O ~~LI .
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 7 00 OP-e.~ Bu\/\ :'.:(~'d
Assessor's Parcel Number: Sub. Lot Block -----
Building or Service Type: Ke<'4elll±iC\ \ #Bedrooms: 2 Garbage Disposal(Y/N)-¥--
.~1l~s Distance to Nearest Community Sewer System: 2
Was an effort made to connect to the Community Sewer System: LI\ Q
TypeofOWTS 1)1' Septic Tank I D Aeration Plant I D Vault I D Vault Privy I D Composting Toilet
D Recycling, Potable Use D Recycling j D Pit Privy I D Incineration Toilet
D Chemical Toilet D Other
Ground Conditions Depth to 151 Ground water table j Percent Ground Slope
Final Disposal by 11[.. Absorption trench, Bed or Pit I D Underground Dispersal I D Above Ground Dispersal
-D Evapotranspiration D Wastewater Pond I D Sand Filter
D Other
Water Source & Type J'..Well j D Spring I D Stream or Creek I D Cistern
D Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? D Yes ~No
Applicant acknowledges that the completeness ofthe 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 ofthe evaluation
of the application; and the issuance ofthe 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.
10/3 / 17
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: \'2~ Perk Fee: Total Fees:
f J.-3-Fees Paid: I :z_ 3
Issue Date: Balance Due:
BUILDING/ PlANNING DIVISION' ./)Jud)~
Signed Approval