HomeMy WebLinkAboutApplicationIle Garfield County
Community Development Department
RECEIVED 108 8`h Street, Suite 401
Glenwood Springs, CO 81601
MAR 2 8 2018 (970) 945-8212
GARFIELD COUNTr'S w.garfieid-countv.com
COMMUNITY DEVELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
CA New Installation 1 El Alteration
0 Repair
WASTE TYPE
Et Dwelling 0 Transient Use
1
0 Comm./Industrial f 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: -1c3PuCWi ct_ L -k ry 4 f Phone: (41 J ) • a • /3 b i
Mailing Address: {gLo O 7 Casty.,- 1 i `� a [ `t &Yt& C y
Email Address: Dav-t, Ca 1pcu 1) w
Al 6
Contractor: t,,G.1 A L-}c-rc..La
Mailing Address: -2L/ ���U -1 ft�� .)`t'
Phone: ( c) 2o) 3 0 t - 173 I
A) u4 C 019 P
Email Address:.Dvc- ivoJai')L k c6v4;4-.5 La ,
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
N /i SSO, 9 --nD jt' 1' ' 19 Sam gCkn� ci'I
Assessor's Parcel Number:
Building or Service Type: N 6,4 iews1'1
Sub.i Lot Block W, -..�- #Bedrooms: Garbage Disposal(YC)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Fl Septic Tank
❑ Aeration Plant { 0 Vault
0 Vault Privy
Composting Toilet
O Recycling, Potable Use
0 Recycling
O Chemical Toilet
0 Pit Privy
0 Incineration Toilet
0 Other
Ground Conditions
Depth to lst Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit
0 Underground Dispersal 1 0 Above Ground Dispersal
O Evapotranspiration I 0 Wastewater Pond I 0 Sand Filter
O Other
Water Source & Type
Effluent
Well
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes ❑ No
Applicant acknowledges that the completeness of the application is conditinnal 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 informati n which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
777//y
Date
OFFICIAL USE ONLY Paid, .c9 (5.18 u ba. ' 2 3. O0
Special Conditions:
Permit Fee:
$ /QS. 00
Building Permit
Perk Fee:
Septic Permit:
BUILDING/ PLANNING DIVISION:
Total Fees:
OG
Issue Da1ei412'4I I�
Fees Paid:
WqS °O
Balance Due:
0.00
Signed Approval
'4/241'0*
Date