HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
1OB 8th Street, Suite 401
Glenwood Springs, CO 81601
l970l94s-82L2
www.Farfield-countv.com
OF CONSTRUCTION
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Non-DomestictrE Transient Use n Comm./lndustrialDwel
Û Other Describe
INVOTVED PARTIES
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Email Address:
Phone: (q?O )Property Owner:
Mailing Address:
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Emait Address l+l. \ @ ÍçJC,aå.L4LI Eãtfr^ic-tuLliá | crØrt
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Engineer:Phone:
Mailing Address:
Email Address:
PROJECT NAME AND TOCATION
BuildingorServicerype:3.%eÐG¡llt*l-#Bedrooms:-GarbageDisposal(Y/Nl{,
Was an effort made to connect to the Commun¡ty Sewer System:TêS
Distance to Nearest Community Sewer System:
Assessor's Parcel Numb"t' 4ðtl3 tgÍLL34í$ub.
Job Address:
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E Aeration Plant E Vault E Vault Privy I ComRostingToiletÍl- Septic Tank
E Recycling, Potable Use E Recycling E P¡tPr¡w E lncineration Toilet
E other
Type of OWTS
E chem¡cal To¡let
Percent Ground SlopeDepth to ld Ground water tableGround Conditions
E Underground Dispersal E AboveGround DispersalE[ Absorption trench, Bed or Pit
E Sand FilterE Evapotransp¡rat¡on E Wastewater Pond
E other
Final Disposalby
E Spring E StreamorCreek E c¡sternE wellWater Source & Type
Ff Community Water System Name "ÍOhtr.I ıe êÈ%aôlù*tÍ,
Wlll Effluent be discharged directly into waters of the State? E Yes Flfl¡oEffluent
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional Ypgn such further
niandatory and addit-'lonal test and reþorts as may be required by the local health de.partment to be
made and'furnished bv the applicant or by the local 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 reguìations made,.information and.reports submitted
herewith and required tó be submitted by the applicant are or will be repres.ented to be true and
correct to the belt of my knowledge and bclicf and arc dcsigned to be relied on by the.local
department of health in'evaluatinf the same for purposes of issuing the. permit a.pplie.d for herein. I
further understand that any falslflcatlon or misrepresentation ttray result irt tlre 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 the required information which is correct and accurate to the best of my knowledge.
Owner Print and Sign Date
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OFFICIAL USE ONIY
ffiicñ )9,Conditions:
Fees Paid
123. DoTotal Fees: -iry.ØPerk Fee:Perm¡t Fee:lz2.ø
Balance Due:lssue Date:gBuilding Permit Septic Permit:
BUITDING/ PLANNING -13^zslA
Date