HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-8212
www.ga rfield-countv.com
TYPE OF CONSTRUCTION
New lnstallation E Alteration tr Repair
WASTE TYPE
Ø(Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
t Other Describe
INVOLVED PARTIES
MailingAddress: lL41 A4 leb ¿&r4¿e44Lr2, êê Qlâ?^}
Email Address:
Property Phone:
Phone:Contrector:
Mailing Address:
Email Address:
Øt60
Phone:
ø4Mailing Address:
Email Address:
PROJECÍ NAME AND TOCATION
D¡stance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Job Address:
Building or Service Type:þât ñut1 lÛl-
Assessor,s parcet Numb er, 231h8âlW s"A.
ffBedrooms: "t Garbage Disposal(Y/Nl N
¿tdart6ú'ã;ã;î¿ tott'!î'4 Btock 13
Composting ToiletnE Aeration Plant E Vault E Vault Pr¡W,{ SepticTank
E lnc¡nerat¡on ToiletE Recycling El P¡t Pr¡wE Recycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to 1* Ground water tableGround Conditions
E Underground Dispersal tl AboveGround Dispersal$,Absorption trench, Bed or Pit
E Sand FilterE Evapotransp¡ration E Wastèwater Pond
E Other
FinalDisposalby
E Spring E Stream or Creek E cisternE*well
E Community Water System Name
Water Source & Type
Will Effluent be discharged directly ¡nto waters of the State?E Yes S-noEffluent
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditiona! gpgn such further
"iänOaiow
ànd addii'lonal test and reþorts as rrlay be required by the local health de.partment to be
made and'furnished bv the applicant ilr by the loial health department for purposed of the evaluation
of the application; and the isiúance of the permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance with rules and regulations made,-information and.reports submitted
herewith and requíred tó be submitted by the apþlicant are or will be represented to be true and
correct tu tfie beit of nry knowledge and belief and are designed to be rclicd on by thc.local
department of health in-evaluating the same for purposes of issuing the.permit a.pplied for herein. I
further understand that any falsifiıation or misrepresentation may result in the denial of the
aþplication 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.
Owner and Sign Date
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5r-r l** Duul 6- tr/8 A)
OFFIC¡AI USE ONIY
Ðo rÞSpecial
þees Paid:f)3. oorotarFees:
¡ 2?. loPerk Fee:
a6N6Pérmit Fee:
-
l27,oo
Balance Due:dlssue Date:*itsltSSeptic Permit:
5€?f r,to{ã:-Building Permit
L-/BUITDING/ PTANNING DIVISION:
Í
Date