HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
RECEIVED 108 8"' Street, Suite 401
5 2018 Glenwood Springs, CO 81601
SEP (970) 945-8212
GARFIELD COUNWt w.garfield-countv.com
COMMUNITY DEVELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Ig New Installation
WASTE TYPE
I 0 Alteration
0 Repair
0 Dwelling
0 Transient Use
1 0 Comm./Industrial 1 0 Non -Domestic
IN Other Describe
INVOLVED PARTIES n
Property Owner: wpb it1
Mailing Address: /0 .y I C t :3i 1 VT,' �S-
Phone: ( Q70
v74- iv_a
Email Address: W��iv"dt- c @? vAi (L N
Contractor: -c -E r
Mailing Address
Email Address:
Engineer:
, Phone: (; _ )
s eF
Phone: j )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: /0 Gal CR 31(
Sr LT-
Assessor's
T
Assessor's Parcel Number: Sub.
Building or Service Type: 164-/kii
Distance to Nearest Community Sewer System:
Lot Block
#Bedrooms: Garbage Disposal(Y/N)
r1 14 S
Was an effort made to connect to the Community Sewer System: /D
Type of OWTS
CSI Septic Tank ❑ Aeration Plant 0 Vault 0 Vault Privy I ❑ Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions
Depth to 15' Ground water table /d0
Percent Ground Slope /0 `2a
Final Disposal by
Water Source & Type
Effluent
pf Absorption trench, Bed or Pit 1, 0 Underground Dispersal L ❑ Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond 0 Sand Filter
O Other
Well I 0 Spring
O Stream or Creek f 0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes ip 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 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 information which is correct and accurate to the best of my knowledge.
{
Property Owner Print and Sign Y
Date
OFFICIAL USE ONLY
Special Conditions:
Pe mit Fee:
12`) .D0
Perk Fee:
C -o • DO
Septic Permit:
SEpI 545
Building Permit
Total Fees:
oo
BUILDING/ PLANNING DIVISION:
Issue Date:
•
IL
Signed Approval
Fees Paid
Balance D
-lso.oc
9%-2o>$
Date