HomeMy WebLinkAboutApplicationGarfield County ONS¡TE WASTEWATER
TREATMENT SYSTEM
(owrsl
PERM¡T APPTICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 8L601
(970194s-82t2
www.ga rf ield-cou ntv.com
WPE OF CONSTRUCTION
New lnstallation tr Alteration tr Repair
WASTE TYPE
E¡ Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
INVOIVED PARTIES^
Property Owner:
Mailing Address:
Email Address:
Phone:
ò g bo L
Contractor:Phone:è { /'*)
Mailing Address:
EmailAddress:a^^ærw
Engineer:Phone:
Mailing Address:
Email Address:0 Ò
PROJECT NAME AND LOCATION l^r 2-
Job Address:Lonå,.., ,| ff)¡nnn l-.', r.t I ut ) <_
Assessor's parcet Numb eïWub.
-
LotlL Block
-Building or Service Type:\ì pws<-#Bedrooms:1 Garbase oisposalÐw)-
Distance to Nearest Community Sewer System:/Ö rnî
Was an effort made to connect to the Community Sewer System:
Type of OWTS EÑseptic Tank E Aeration Plant E vault E vault Priw tl Composting Toilet
E Recycling, Potable Use E Recycling E P¡t Prívy El lncineration Toilet
E Chemical Toilet E other
Ground Conditions Depth to l't Ground water table Percent Ground Slope
Final Disposal by plAbsorption trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type þwett E Spring E stream or Creek E cistern
E Community Watêr System Name
Effluent Will Effluent be discharged directly ¡nto waters of the State?E Yes E ¡¡o
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test ancl 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 ahd òonditions as deemed
necessary to.insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the apþlicant 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 oi issuing the permit applied for herein. I
further understand that any falsification or misrepresentation mayiesult in the dehial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
alreh d
ow that I have and unde
nwh
Owner and S¡gn
and Cert¡f¡cation above as well as
and accurate to the best of my knowledge.
_)
Date
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OFFICIAT USE ONLY
Special Conditions:
"'Si2j.oô l#iä.*Total Fees:62qRæ Fees Paid: ./1 \lâ3,tj()
Building Permit
éïr-{{4t^r¿r
lssue Datã:-
I /</lp-,Balance Due:8¡¡n.ø
BUTLDTNG/ PIANNING DtvtstON ß
Signed Approval Date