HomeMy WebLinkAboutApplicationGarfteld County ONSITE WASTEWATËIì
TREATMENT 9YsTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
íg70l94s-82t2
www.ga rfield-countv.com
TY'E OF CONSTRUCTTON
,E[ New lnstallation E Alterat¡on tr Repair
wAsTE WPE
J[ Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Propefi owner: "Sarç \ 'Tøw-t €pr-s Phone: (qn | 7f?o*ä1t2
Mailing Address
Email Address:€næ ntzs,o ı fto¿-.LÞY'^*
Contractor:Phone: ( )
Mailing Address:
Email Address:
^4--^hø-Ðr\-
Engineer:Phone:
Mailing Address:
Email Address:
PROIECT NAME AND TOCATION
Job Address 2,5,9ì t'E- 3çE t7Ê
Assessoy's Parcel Number: zHDf(2ãqC?ClDIÁsub. 0t¡n<ß,¡ánrit ÊAN¿tt LotfËAL Block_
Building or Service Type:
-
frBedrooms:
-
Garbage Disposat{Y/NLA-
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:Ê
Type of OWTS .Ef Septic Tank E Aeration Plant El Vault E Vau¡t Pr¡W fl Comnost¡ng To¡let
E Recycling, Potable Use E Recycling E Pit Prirry E lncineration Toilet
E chem¡cal To¡let E other
Ground Conditions Depth to ls Ground water table _Percent Glound Slope
Final Disposal by E Absorption trench, Bed or P¡t El Underground Dispersal E AboveGround Dispersal
E Evapotranspiration El Wastewater Pond E Sand Filter
E other
Water Source & Type p Well E Spring E Stream or €reek E c¡stern
E commun¡tyWatersystem Name
Effluent WillEffluentbedischargeddirectlyintowatersoftheState? El Yes ENo
CERTIF¡CATION
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
applícation 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 wh ts and accurate to the best of my knowledge.
Ot ^ zñ-18
Property Owner Print and Sign Date
OFFICIAT USE ONLY
Special Conditions:
Permit Fee: -Iterk Fãe:t\ r*Tolal FeesJ ,Fees Paid:
Euilding Permit Septlc Permit:
5c.,,Ol .6331 lssue Date:Llf9rtn Balance Due:
Ø
BUITDTNG/ PTANNTNG
Date
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