HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
RECEIVEj8 8th Street, Suite 401
GlenwoodI}Springs, CO 81601
AUG 2 4 201h (970) 945-8212
GARFIELD COtYlnrfleld-countv.com
COMMUNITY DEVELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
O New Installation ! 0 Alteration
0 Repair
WASTE TYPE
O Dwelling
0 Other Describe uetacnea garage to oe constructea t3o4sT
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES -
_
r
Property Owner: 13aPhone: ' } ' e � f � � E (
Mailing Address: 4i4o iviountain Jprings rioaa, ulenwooa prings, i iou l
Email Address: 9JwanwogWgmaii.com
Contractor: er Phone: (`j 14-ypL- 13.3L4
Mailing Address: 4 /4o iviountain apnngs mac], uienwooa Jprings, L U. is iou lull i
Email Address: g)walicyov,v gmail.com
Engineer: ramilY TomTTe flans-
Phone: (6UU )
4t3'L-U4134
Mailing Address: L I L I C3ounaary Jireei, J Luta, beauTort, JLi LyUt L
Email Address: snawnnasteeieureaesignnp.com
PROJECT NAME AND LOCATION
Job Address: 4/45 ivi0untain dpnngs i- oa0T GienwOoa Jprin U I
Assessor's Parcel Number: 2185191_00-miab. ivtoUniain springs r Lot o sloe
Building or Service Type: uarage - aeptic I Dain #Bedrooms: 1 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System: IWH
Was an effort made to connect to the Community Sewer System: N/A
Type of OWTS
O Septic Tank
0 Aeration Plant
Vault
0 Vault Privy n Composting Toilet
O Recycling, Potable Use ` 0 Recycling
0 Pit Privy
Ground Conditions
O Chemical Toilet
0 Incineration Toilet
0 Other
Depth to 15t Ground water table -td Percent Ground Slope °- 1 07°
Final Disposal by
O Absorption trench, Bed or Pit
® Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
Effluent
Ll Well
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes 0 No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may hp regiiired 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 sarne 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
Ied the required inf ation which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
r
Date
OFFICIAL USE ONLY Q_ 1 L I a ,il--1` /c5. 06
L
Special Conditions:
Perrpit Fee:
Pye�rk�Fee:
Total Fees:
Fees Pald:
Building Permit
.'g.1—TE,""
Septic Permit:
SLS- -
Issue D te:
19111
Bala ce ue:
do
BUILDING/ PLANNING DIVISION:
„l Y 2,4 J
Signed Approval Date