HomeMy WebLinkAboutApplicationÇ*rJield C*unty ONSITE WASTEWATER
TREATMËNT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-82L2
www.ga rf ield-cou ntv.com
TYPE OF CONSTRUCTION
tr New lnstallation Alteration Repair
WASTE TYPE
ø Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
PARÎIES
Property Owner:
Mailing Address:
*s
o
Phone: ('1 l'o )S +'1 ?J ?Gq
Lo
¡rtrS (: rcc..,,o-{,o..'..Email Address
à>n-t e Phone: ( )Contractor:
Mailing Address:
Email Address:
Mailinp Address:
Phone: ( )Engineer:
Email Address
Was an effort made to connect to the Community Sewer System
*Srri \
\..s lot ni l\ Block d A
Distance to Nearest Community Sewer System:
Assessor's Parcel Number:
Building or Service Type:
PROJf,CT NAME AND
aJob Address:
#Bedrooms: tT Garbage oisposal@ru)-
?t'lJo¡3ø*a__S-sru.
Â0.,".
Ef SepticTank EI Aeration Plant E Vault EI Vault Privy fl Comnosting Toilet
E Recyeling El tit rrivy E lnc¡nerât¡on To¡letE Recycling, Potable Use
Type of OWTS
E chemicâl Toilet E other
Ground Conditions Depth to l't Ground water table Percent Ground Slope
Absorption trench, Bed or P¡t Underground Dispersal El Above Ground Dispersal
E Evapotransp¡rat¡on E Wastewater Pond E Sand Filter
E other
Final Disposalby
,Ø well E Spring E stream orCreek E cisternWater Source & Type
E Community Water System Namê
Effluent Will Effluent be discharged directly ¡nto wateß of thc Statc? E Yes E! tlo
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 provjy'ed th9 rgryúred information which þ correct and accurate to the best of my knowledge.
M%.- trtliq^/LlnreS y-a3-rB
Property Owner Print and Sign Date
Special Conditions:
Permit Fee:A>Perk Fee:Total Fees:Fees Paid:Þıaß
Buildíng Permit Seotic Permit:
Se'pr- os-ìt-l?(ô
lssue Date:6tJLtt2 Balance Due:
S-2*+-2Ð/8BUITDING/ PTANNING
Date