HomeMy WebLinkAboutApplicationGarfield County
ommunity Development Department
RECEIVED 108 8t' Street, Suite 401
Glenwood Springs, CO 81601
DSC 32
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GOMMU
(970) 945-8212
w.garfield-county.com
TYPE OF CONSTRUCTION
New Installation T
WASTETYPE
Dwelling
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
❑ Transient Use 0 Comm./Industrial
El Repair
0 Non -Domestic
0 Other Describe
1MUflI -
VCr% DARTIFC
Property Owner: Al Ile "feu/ / Phone: ( `0775 ) 379 55 Z 3
Mailing Address: eqt C -111T
-‘ S� ( (0 fev52
iN ca.17iV] c Sop i , I] e_1
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Contractor: 7f.4 1. n 54-�tiC.fi ar? In C- Phone: (T7 ) 574— 7 / 9 Z
Email Address:
Mailing Address: _ ZD 1 g� [ 4 r t
Email Address: l ,et( Qg q a '1. Ca'r•.
J � 5
Engineer: �,- nl P_S-4a r — 2 �
��1yy
Phone:120 ) �f g 4 c
Mailing Address 4'1ss i.�1 I(
Email Address: 1.fi 5-4 e .lj GS 'f ' Vic •'L
PROJECT NAME AND LOCATION -
Job Address: 76 Q LA Z-14
Assessor's Parcel Number:Zl7$'OZ$ - e1- iti O Sub.f c4i I4 //c y Lot /6, Block
Building or Service Type: -e.-5 #Bedrooms: 1-1" Garbage DIsposal(Y/N) l�
/5
Distance Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank I 0 Aeration Plant 1 0 Vault 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy r ❑ Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Depth to 15' Ground water table
Percent Ground Slope
$ Absorption trench, Bed or Pit j 0 Underground Dispersal j 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond[ 0 Sand Filter
❑ Other
Well F:1 Spring 0 Stream or Creek
0 Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes 14 No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upnn 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 an 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
haveOfovi • ed the required information which is correct and accurate to the best of my knowledge.
• �I
g.
opert Owner Print and Sign 4
/2�31lR
Date fI
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
1,2- 3.00
Perk Fee:
10.00
Total Fees:
2-1"3 . Ob
Fees Paid:
21'3.00A
Building Permit
13 [Al V- 55 4I)
Septic Permit:
SEPT- 5.5 61, (
Issue Date:
. 1 1G
Balance Due:
BUILDING/ PLANNING DIVISION:
9 `- "H F
Signed Approval
Date
Pp.+ 21-3.00) A- (boo )'('I!'