HomeMy WebLinkAboutApplicationGOUq(}p hmunity Development Department
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C,p,FtF�E�.' 1 108 8`" Street, Suite 401
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Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYF CONSTRUCTION
Property Owner: fj ■, — ] -r Phone: (9/e_) 57 -/762
pp
Mailing Address: jPa _17014 7/7.2 - 619p76 5.--c.
Contractor: i4? j�7G t/rr Phone: (970 ) 579 /74.
New Installation
•
Alteration
•
Repair
WASTE TYPE
Job Address: n 0ii7C X14 2 Q j/4'S.-)
Assessor's Parcel Number: c2 7o? 7 Sub. 3621 Lot b 1 Block00 e
-
Building or Service Type: #Bedrooms: Garbage Grinder Nb
• Non -Domestic
• Dwelling • Transient Use
• Comm./Industrial
• Other Describe
0 Aeration Plant lI 0 Vault j0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
1 0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
INVOLVED PARTIE
Property Owner: fj ■, — ] -r Phone: (9/e_) 57 -/762
pp
Mailing Address: jPa _17014 7/7.2 - 619p76 5.--c.
Contractor: i4? j�7G t/rr Phone: (970 ) 579 /74.
Pd Mailing Address: 4 // 7 2 5.-', 4,1, 457/,66-..?
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION �
Job Address: n 0ii7C X14 2 Q j/4'S.-)
Assessor's Parcel Number: c2 7o? 7 Sub. 3621 Lot b 1 Block00 e
-
Building or Service Type: #Bedrooms: Garbage Grinder Nb
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
0 Septic Tank
0 Aeration Plant lI 0 Vault j0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
1 0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Depth to 15` Ground water table
Percent Ground Slope
_
Final Disposal by
0 Absorption trench, Bed or Pit
1 0 Underground Dispersal I 0 Above Ground Dispersal
❑ Evapotranspiration
f 0 Wastewater Pond
L i 0 Sand Filter
T
❑ Other
❑ Well
0 Spring
0 Stream or Creek
I 0 Cistern
Water Source & Type
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? ❑ 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. 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 acknowledge at 1 have read and understand the Notice and Certification above as well as
have provided t
information which is correct and accurate to the best of my knowledge.
Prope
nd Sign
Date
OFFICIAL USE ONLY
Special Conditions:
4f p�'i't'e / 4 A 6j pi ,lCce55Cry 54'U c/u/e(Q.4047704i
Permit Fee:
I13.0O
Perk Fee:
ISD. c0
Total Fees:
273. 06
Fees Paid:
233.DO
;1.1 l• g Permit
—3g(01
Septic Permit:
C —35Stv'/
Issue D e:
91)1-1Is
Balance Due'
DIV:_Xi
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APPROVAL
DATE
IA 421'3) 5/I57'j 2- /5"