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HomeMy WebLinkAboutApplication3 Garfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-countv.com TYPE OF CONSTRUCTION ❑ New Installation WASTE TYPE Dwelling ❑ Transient Use ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION Alteration ❑ Repair 0 Comm./Industrial f Non -Domestic ❑ Other Describe INVOLVED PARTIES Property Owner: P(a'r \(1C ( (1 P1 Phone: (y7D ) al r9 - 0 9 3 Mailing Address: (o Laj-- &I -4p ril Q4 t CrQ K Tr I Email Address: f laCfaff• ` --P , (dYY) Contractor: Phone: (910 ) L US • gob() Mailing Address: bri ( Z� 7Cro(. % (orePe S -'e I' ICC 3 8 l J S Email Address* ER lArkA o 00 1k9"1_R~CL r1nCi\ O7 ' Ce 1,' Engineer: r+p }7Phone: ?7i9 ) 2%i-2 Mailing Address: S Ale) c,Cf, ) LA C.'yWfriCe+t ''ifi'4 C ki- � Email Address: k 4r"a9 R / >, ( Wive • Cess wk. PROJECT NAME AND LOCATION Job Address. ' a:. 1 -al 0e 4 f I 4 r Assessor's Parcel Number:AU, 002. 00•b12'Sub. fhr R LSf\ kl ll'r flZalthLoiTe_S3Bloc k Building Service Type: Q�,t.C+! zdetit., [ #Bedrooms: II Garbage Disposal(Y/N) Al or u_ Distance to Nearest Community Sewer System: Z 04 :ie. Was effort made to connect to the Community Sewer System: J42 an Type of OWTS 0 Septic Tank L ❑ Aeration Plant !❑ Vault I 0 Vault Privy I Composting Toilet ❑ Recycling, Potable Use I 0 Recycling 0 Pit Privy [❑ Incineration Toilet ❑ Chemical Toilet I 0 Other Depth to 1g Ground water table Percent Ground Slope Ground Conditions Final Disposal by Tif Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter ❑ Other Water Source & Type ❑ Well © Community 0 Spring Water System 1 0 Stream or Creek 1 Name 0 Cistern - Effluent Will Effluent be discharged directly into waters of the State? 0 Yes .- 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. luLai 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 8-11-18 Date OFFICIAL USE ONLY CJ, 8/9..0 les t Lke23o i- `5,c:5 53- DCI Special Conditions: Building Permit Perk Fee: Septi,s3 r it: ^ BUILDING/ PLANNING DIVISION: Total Fees: 45 co Fees Paid: Issue 91'r Signed Appr Bal nce Due: co a� Date