HomeMy WebLinkAboutApplicationre Garfield County
RECEIVL�E' imunity Development Department
108 8th Street, Suite 401
SEP 14 2018 Glenwood Springs, CO 81601
(970) 945-8212
GARFIELD COUNT
COMMUNITY l]EVELOPME caw. arfield county.cam
Fowl
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation _ I Alteration
WASTE TYPE
[ 0 Repair
Irl Dwelling L❑ Transient Use 0 Comm./Industrial 1 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: E_'f/f 6 d JL- Phone: (q 70 ) 37 q 46,07—
Mailing
60ZMailing Address: / Z- Z- /‘4C -A-156,..) i -A �E "-��+� PLC'S 657 / l00 I
Email Address: if: \AA' t? G °0-5 4'^'S' 2oG,'7or.i ,(,d Ai
Contractor: %' B. D . Phone: ( 1
Mailing Address:
Email Address:
Engineer: /x/7,4 Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: / 2-2-
Assessor's Parcel Number:Z3150L1030/ 7 Sub. G%5/ -3A044 gitAelf Lot /7 Block fr f ✓"
Building or Service Type: EX (Si • %1 CIA6 /?AL 41i5 #Bedrooms: Z N6N)
Garbage Disposal(Y/N) l$7
Distance to Nearest Community Sewer System: , /
Was an effort made to connect to the Community Sewer System: /v �A
Type of OWTS
I81 Septic Tank 0 Aeration Plant 0 Vault I 0 Vault Privy ri Composting Toilet
J
O Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1n Ground water table
Percent Ground Sfope
Final Disposal by
Water Source & Type
Effluent
O Absorption trench, Bed or Pit
0 Underground Dispersal j 0 Above Ground Dispersal
❑ Evapotranspiration 1 0 Wastewater Pond
❑ Other
❑ Well + 0 Spring
0 Stream or Creek 0 Cistern
l 1
r0 Sand Filter
Community Water System Name
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 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 inf• ation which is correct and accurate to the best of my knowledge.
rty Owner P4170 ign
Date
OFFICIAL USE ONLY (Its Q
Special Conditions: oV [dG 3 4p �J VA,V►e-i40+a4 , f dot ..CA4 c3i* el Stpt G tekvile 91%(,
l,u li etccovrimod.tF[(�c totaI 116(44+1 of 1%34011"00114 -
Permit Fee:
/75 '01?
Perk Fee:
Total Fees:
4R-4S.C"0
Fees Paid:
$7-5-,06
Building Permit
6112r Lf:2
Septic Permit:
SEPT 6`i` -3
Issue Date:
I�
Balance Due:
�
BUILDING/ PLANNING DIVISION:
I
9(2./261t,
Signed Approval
1 Date