HomeMy WebLinkAboutApplicationE4Earfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New Installation [ Cl Alteration
0 Repair
\VASTE TYPE! _ - - _ TI
0 Dwelling 1 0 Transient Use 1 ❑ Comm./lndustrial 0 Non -Domestic
Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Address: 3 91/ .'{/ ye) J??, €i ''
Email Address:
Phone: (9 "$?
Contractor: 1)w r4'_'
-12
Phone: (_)
Mailing Address:
Email Address:
Engineer: Phone: ()
Mailing Address:
Email Address:
Job A d NAME I�N1�I�LQC+
ob Address:
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: #Bedrooms: Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank
0 Aeration Plant
❑ Recycling, Potable Use
❑ Chemical Toilet
0 Vault 0 Vault Privy 1 ❑ Composting Toilet
O Recycling 0 Pit Privy 0 Incineration Toilet
0 Other
Depth to 15' Ground water table
Percent Ground Slope
Absorption trench, Bed or Pit 0 Underground Dispersal 0
❑ Evapotranspiration
❑ Other
Well
O Wastewater Pond
0 Sand Filter
Above Ground Dispersal
0 Spring
0 Stream or Creek
0 Cistern
❑ Community Water System Name
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 information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
;9-,2o/
Date
OFFICIAL" USE ONLY
Special Conditions:
VW Si elletptCay of 049tr
WU6 'Wilk 0i1'i rovitpull vvccipl.
Permit ee
Perk Fee:
Total Fees:
Fees Paid:
Building Permit
P'Lr_e - 7D
Septic Permit:
CFPT- Soca
Issueate:
4 C!
20
Balance Due:
r
BUILDING/ PLANNING DIVISION:
i
40/1016
Signed Approval Date