HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
l970l94s-82t2
www.garfield-countv.com
TYPE OF CONSTRUCTION
New lnstallation E Alteration tr Repair
WASTE WPE
El Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
EI Other Describe
INVO¡.VED PARTIES
Property owner: (}a C¡tr\ tr-¡L Phone: (a1Qj a\¡S-qòUÎ
Mailing Address;¡r^ì\ åaRs Cr.Ào.-rc.. .\-r.-
Email Address
Contractor¡Phone:14ìs ) âttil- ilq?
Mailing Address:
Email Address \\Àr^\ f ¿ i\ra¡..o\ - 1àr*r
Engineer:Phone:(
Mailing Address:
Email Address:
PROJECÍ NAME AND IOCATION
Job Address:
Assessor's Parcel Number: Sub.Lot Block
Building or Service Type Has,, c&rùß(S #Bedrooms:Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:plÅ
Type of OWTS F SepticTank E Aeration Plant E Vault E Vault Privy f] Composting Toilet
E Recycling, Potable Use E Recycling tr P¡t Pr¡vy E lnc¡nerationToilet
E Chemical Toifet E other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
FinalDisposalby /4 Absorpt¡on trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type f wetl E Spring E Stream or Creek E Cistern
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? EI Yes A tl¡o
. CERTIFICATION
Aoolicant acknowledges that the completeness of the application is conditional Ypgn such further
;ti'#ääór;;d àäãiti"ñ;itesi anO reþorts as may be req'uired by the local health de.partment to be
;;äË;;,]'f;i"irf'ãä Ultñeã-ppiicant br by the loéal health department for pu.rposed.of the evaluation
öitÏãä'óËllðåt¡ã"; ãndt-t'ã¡liiã"èè of thé permit is.subject to such terms and conditlons as deemed
necessarv to insure comólianlJ*ith rules änd regulations made, information and.reports submitted
üãiu-'i,Ïir"ì.r¿ iãqrir"¿ ïö bè submitted by the apþlicant are or will b.e rep.resentqd t9 b9 true and
äãir"ðiìoìLË ¡iü of mv knowlè¿ee and belief ánd are designed to be relied on by the.local
dã;tùiã'ii óihéahh in'evaÍuatin[ the same for purposes oi issuing the.permit a.pplied for herein. I
i¡]¡{Ë; ,;ù;stãnãïträt ãny rálsit''ıation or misreþre'sentation may result in the denial of the
;îiiüt'r¡ófi"uócàt¡on of anV permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I
have provided the required
Property Owner Print and Sign
the Notice and Certification above as well as
correct and accurate to the best of my knowledge.
l()-q- \ì
Date
and
<c5
OFFICIAL USE ONLY
Special Conditions:
Fees Paid:ØTotal Fees: ^/nd273*Perk Fee:$leo 60'6TiZoô
'vff."zolssue Date
r \- 3-\7ÕEpl:qqq4Sept¡c Perm¡t:Building Permit
f4rnÇ-L+qBg
BUITDING/ PLANNING DIVISION
Signed Approval Date
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