HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
Gil 108 81h Street, Suite 401
�rno, Glenwood Springs, CO 81601
toik 13 I -0 (970) 945-8212
ri U coo Ok.garfield-county.com
GP
oll' TYPE OF CONSTRUCTION
0 New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
eif Repair
WASTE TYPE
IA` Dwelling i 0 Transient Use 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: fil-tX t j- W1� -r Phone: ( �) 6/45- -Zai
Mailing Address:
Email Address:
Contractor: 4rit IXC Lt.0 Phone: ( }6) t (�'
� tal
Mailing Address: in t. 5 35 ( id IN V_t . 2_1 t{ 1dt."..1 C ut S'T l.. i✓ t c.. 3'16 y 3 --
Email Address: G; e lkt 6)5, k 1 I,TFLi1M • t oL Vk_
Engineer: 6+7111 itPlc- i_ D (•'N'(K Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:& .}
ati' d.- z
•IJ.S_ t❑
Assessor's Parcel Number: Sub.
Building or Service Type: n.l. 117 #Bedrooms: _ I Garbage Disposal(Y/N)
Lot Block
Distance to Nearest Community Sewer System: l
Was an effort made to connect to the Community Sewer System: N] W
Type of OWTS
pi Septic Tank 0 Aeration Plant
0 Vault
O Vault Privy
❑ Composting Toilet
O Recycling, Potable Use
O Chemical Toilet
O Recycling
0 Pit Privy
0 Incineration Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table 4
Percent Ground Slope e 3- ( " /61
Final Disposal by
Water Source & Type
Effluent
pj Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Sand Filter
O Other
Well
0 Spring
0 Stream or Creek I 0 Cistern
O Community Water System Name
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, 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.
r, it [.4; y/(
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:Total
150
Fees:
Fees Paid:
Building Permit
SepticP rmit:
Sip .--51 3---
Issue Dat
S12,11c
Balance Due:.
BUILDING/ PLANNING DIVISION:
:
1.)
2Q/,
..,
Sig , ed Agp : al
Date
7,1 00, / 3152-, 3I31''