HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
a X011 108 8th Street, Suite 401
to Glenwood Springs, CO 81601
BAR
VIEW C Q 1' vwwG
°70) 945-8212
�� arfield countv.cam
TYPE OF CONSTRUCTION
0 New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
Repair
WASTE TYPE
JO Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
N INVOLVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Contractor:
Mailing Address:
7l4Ip Y OAN4 1, Phone: (t}' ) _1 274 ')3 243
cl 4 j , Ua O o L22_3
Tc.kv •_►' tflJH
Phone: (93D
t( -lis ellf
xl F.L0 ar@c .
23o -Q57
Email Address:
Engineer:
Nef
c
2-0124..J Phone: (
Mailing Address:
Email Address:
PROJECT NAME ANDION
� rr
1P Ci /Q
Job Address:
Assessor's Parcel Number: Sub. Lot Block AlBuilding or Service Type: j! s /2 a C{ #Bedrooms: 3 Garbage Disposalr(Y/N) A
'l,. )Lt l t
Was an effort made to connect to the Community Sewer System: �sp
Distance to Nearest Community Sewer System:
Type of OWTS
u$ Septic Tank 0 Aeration Plant 1 0 Vault 0 Vault Privy ElComposting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Ground water table, T) I ■
Percent Ground SlopeZ` IJ /O
Final Disposalbye' Absorption trench, Bed or Pit
Water Source & Type
0 Underground Dispersal
❑ Evapotranspiration
❑ Other
fs Well
0 Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
0 Spring 0 Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
0 Yes 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. 1
1 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 ackn wiedg hat I have read and understand the Notice and Certification above as well as
hav provii the requir d information which is correct and accurate to the best of my knowledge.
Property swrlJr Print and Sign
':AQ 720e
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees:
Fees Paid: t
Building Permit
Septic Permit:Issue
sgpr-..3t
Date:
II - 2g- f -
Balance Due:
BUILDING/ PLANNING DIVISION: f.�r�
Signe.
��
• p , oval
Date
Pp. 3 lc. a --v, t/i- /Mel 1'I2-/H-