HomeMy WebLinkAboutApplicationOCT 1 3 2017
Garfield County j
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.corn
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
ASTE TYPE
I❑
Alteration
0 Repair
0 Dwelling
0 Transient Use
O Comm./Industrial [❑ Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 44" cSMA I• 41Ccira a.tt-,h,E Phone: ( 305) 9 cLrit)
Mailing Address: Keno t'10 Rd #t 30 - lO 2_ 'C; he, 1 14215-3
3
Email Address: Magi bu s It 4- pse.S e rncs. r (,racy! Ka rct P. poratoylf� ia�e(UJ yt . GO,'v
Contractor:5 ��� k�Uk 1 r } /v•e,-1 Phone: (7 c ) ` -11- 'L l qi5
Mailing Address: 232 Sato (•w-ers 9.A - ie. 23 t3 l sal 4- Co g 1 to
Email Address: erCS ea f1 b t . L 4- v1e.4-
Engineer: r 1 Z ASS o` .
Mailing Address:
Email Address:
Phone: (H'"►O ) l 4 S • (.030S-
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L3OS
5 o2 Cxovnyk,c RA. t c,{ el-te"),:n4 ,q .
1 +kr+2. 8 -no) the r A.koo .(
PROJECT NAME AND LOCATION
2-'3G1t'2'13.OSO2,2Sub.
Job Address:
Assessor's Parcel Number:
Building or Service Type:
S (=
Distance to Nearest Community Sewer System:
eta,
Lot 2 2 Block T hr 7
Ran) e
#Bedrooms: 3 Garbage Disposal(Y/N) vrc
Was an effort made to connect to the Community Sewer System: /VA -
Type of OWTS
SL Septic Tank
0 Aeration Plant
0 Vault i 0 Vault Privy
Composting Toilet
O Recycling, Potable Use
O Recycling
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 15" Ground water table
Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit
Water Source & Type
Effluent
Underground Dispersal
0 Above Ground Dispersal
0 Evapotranspiration I 0 Wastewater Pond
0 Sand Filter
O Other
❑ Well —I 0 Spring I 0 Stream or Creek -J 0 Cistern
y1 Community Water System Name 3+%r1129 un -in t1Je:11
Will Effluent be discharged directly into waters of the State?
❑ Yes 0 No
V)
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, informat‘pn 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.
-) - .:.Q
raperty Owner Print and Sign Era_
OFFICIAL USE ONLY
‘c1�Zltn
Dater/ (
Special Conditions:
Pe it Fee:
o0
Building Permit
Perk Fee: Total Fees: Fe s Paid:
- /23, no 123QO
Septic P r+nit. Issue Date: Balance Due:
1s\ 'kg EVA:rg-2011-
if.7. BUILDING/ PLANNING DIVISION:
Signed Approval
f/7/2e i
Date