HomeMy WebLinkAboutApplicationGarfield County
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Community Development Department
108 8th Street, Suite 401
5c4 144 ig1 Glenwood Springs, CO 81601
rj(I fi31 '� (970) 945-8212
www.garfield-county.com
10,10
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
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Property Owner: It Svc;, Zc7iitN S ►et tC / Phone: [ t):Li o 1 - 5R 1
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Mailing Address: t 13 fano;- tZwd-,CL -. cexAo:�ClC\le l co t(ELc
Email Address: 4 d Lktr.[ Ci & s lug C L- G. t i • COvv‘
• New Installation
Mailing Address: DA t10 I y 1:) r c c k lir‘ , (1I. Ka v or A. S-- Co 1bb j
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Email Address: Aivi L C6;^_a 1 rL: c 1 i it i s1C° `�I C' Lv• CAi 1 ' CO
•
Alteration
•
Repair
WASTE TYPE
PROJECT NAME AND
LOCATION
'141 yNcty0 y,,, s,., ,1
---‘..Citi.),
Job Address: t2, 0 C
z- COor c CO
• Dwelling
•
Transient Use
Sewer System:
connect to the Community
• Comm./Industrial
Sewer System:
• Non -Domestic
• Other Describe
Type of OWTS
0 Septic Tank 0 Aeration Plant 0 Vault
0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy I 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground
Slope
INVOLVED PARTIES j1
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Property Owner: It Svc;, Zc7iitN S ►et tC / Phone: [ t):Li o 1 - 5R 1
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Mailing Address: t 13 fano;- tZwd-,CL -. cexAo:�ClC\le l co t(ELc
Email Address: 4 d Lktr.[ Ci & s lug C L- G. t i • COvv‘
Contractor: Afri4 L. 1.1I65Iry C.4 ie,.1 in /-. u i.,0 1C rvua1Ck'Phonee: (q3O ) e 31
Mailing Address: DA t10 I y 1:) r c c k lir‘ , (1I. Ka v or A. S-- Co 1bb j
nn t
Email Address: Aivi L C6;^_a 1 rL: c 1 i it i s1C° `�I C' Lv• CAi 1 ' CO
Engineer:
Phone: (, )
Mailing Address:
Email Address:
PROJECT NAME AND
LOCATION
'141 yNcty0 y,,, s,., ,1
---‘..Citi.),
Job Address: t2, 0 C
z- COor c CO
Assessor's Parcel Number:).
Building or Service Type:
Distance to Nearest Community
Was an effort made to
i I4 IO:2.00, Sub. aLoy avkct 2ece.v (..le_ Lot C Block
#Bedrooms: ,Z_ Garbage Disposal i+
Sewer System:
connect to the Community
Sewer System:
Type of OWTS
0 Septic Tank 0 Aeration Plant 0 Vault
0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy I 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground
Slope
Final Disposal by
0 Absorption trench, Bed or PitI 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type
0 Well 0 Spring
' 0 Stream or Creek
Name
1 0 Cistern
0 Community Water System
LEffluent I Will Effluent be discharged directly into waters of the State? 0 Yes 0 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 required inforation which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
l
Date
- [ 7
OFFICIAL USE ONLY _
Special Conditions:
Permit Fee:
17'"
Perk Fee:
n46 •
Total Fees:
12 3• bo
Fees Paid:
123.6o
_
Building Permit
t3Lte -492 -
Septic Permit:
Sept- it
Issue Date:
►\-iku
Balance Due:
BLDG DIV:41)41415.-
1 1/14/1417
APPROVAL
_
DATE
D. # 1 2.3 .bo; ,l uo�--