Loading...
HomeMy WebLinkAboutApplicationGOUq(}p hmunity Development Department �iF1f El.�P�E C,p,FtF�E�.' 1 108 8`" Street, Suite 401 �MMl1E�1�'f 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 � � Y�"'�'` //4//,BLDG APPROVAL DATE IA 421'3) 5/I57'j 2- /5"