HomeMy WebLinkAboutApplicationGarfield County
ReGOVel) Community Development Department
,o 108 8`1' Street, Suite 401
kyN•'(`(Glenwood Springs, CO 81601
�'EL �� tJpNF7`� (970) 945-8212
IoM UN�1'f �F www.garfield-county.com
TYPEOF CONSTRUCTION
New Installation
WASTE TYPE
XI Dwelling l 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
1 0 Comm./industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: t »r -r+ 4CAR /iLe/rt- M hone: (7 j 1i.1'‘9.3,o2
Mailing Address: 1/41 t// If?f1v M /
Email Address: L/A/L'L • riga/itat-19pr/j%`M.• • eVrri
Contractor: OW 1V
Mailing Address:
Email Address:,r
Engineer: i•• / P 1 471 Phone: (171±)-9
)-9
Mailing Address: 9.Z3 62f4 - 4-10-4 if m -i( 0/
Email Address: Droe Gf' /// e , 1149
)74
Phone:1 )
PROJECT NAME AND -60- LOCA ON2_ __�
Job Address:% _d/II -' Q ! f 03
Assessor's Parcel Number: r J Sub. V- L 1 l.e. Lot 4 Block
Building or Service Type: 1`(} -L}� 11 Lt ( t #Bedrooms: Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
❑ Aeration Plant 0 Vault , 0 Vault Privy I E Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy [ 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Type of OWTS
Ground Conditions
Final Disposal by
DEL.SeptIc Tank
D epth to 1st Ground water table { Percent Ground Slope
Absorption trench, Bed or Pit I 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond ❑ Sand Filter
O Other
Water Source & Type 3g Well
Effluent
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes ❑ No
Permit Fee:
173.Oc�
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon siirh 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 termsand 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. 1
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.
6Yfe-e .(vezifyi
Property Owner Print and Sign
!r
�
Date
OFFICIAL USE ONLY
Special Conditions:
Perk Fee:
—1\1 j
IS('
Total Fees: �2
bb },
J
Building Permit Septic Permit: Issue Date:
5L# e -SUS S -C,® (Si 21:61
Fees Paid:
3. OD
Balance Due:
BUILDING/ PLANNING DIVISION:
Signed Approval
/30.0
Date
Date
PL . 41)/.3 00) 0( 23V0, i/q,c