HomeMy WebLinkAboutApplicationp Community Development Department
VI J ,�� 108 gth Street, Suite 401
�0 `� Glenwood Springs, CO 81601
(970) 945-8212
www.garfieid-countv.com
leGarfield County
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
Dwelling 1 0 Transient Use j 0 Comm./Industrial M Non -Domestic
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
_Repair
INVOLVED PARTIES p _ _
Property Owner: �. YI' 1�l 1 L� j ��L�'l Q 5 Phone: NTG) c72:,) 7R
Mailing Address:1 Z 001.0r1 I YO Lz e 6 61 OI% •-' "w o a d 5P )--s? C1)?/6 a
Email Address: .61YC1vv9-2.v S oyi S C 0P c
Contractor: Phone: ( )
Mailing Address:
Email Address:
Engineer: Co,- \Cl O 5 ), l
Mailing Address::27 FA 1 w Lek c r.'--€'-
Email Address: CO 1'-1 i T v 3 L ' wa.`l'c Y"1
PROJECT NAME AND LOCATION
Phone: (f ) 3 °tr5T5
Go rbo r tQ co 6I 623
Job Address: • C.ov
Assessor's Parcel Number: Sub. Lot Block `/
#Bedrooms: Garbage Disposal(Y/N) 1' P -S
Building or Service Type: 11,.e5 A 0 Y1
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
f9 Septic Tank I 0 Aeration Plant 0 Vault I 0 Vault Privy I ❑ Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy f 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Depth to ist Ground water table
Percent Ground Slope
Final Disposal by
VI Absorption trench, Bed or Pit E 0 Underground Dispersal
O Evapotranspiration 1 0 Wastewater Pond 0 Sand Filter
0 Above Ground Dispersal
O Other
Water Source & Type ' well 0 Spring -7 0 Stream or Creek
0 Community Water System Name
Effluent
❑ Cistern
Will Effluent be discharged directly into waters of the State?
0 Yes
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon Mich 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 on 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
have provided the required information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Building Permit
Perk Fee:
Septic Permit:
SEF
Total Fees:
Ac,
Fees Paid:
Issue D atrIS1 v1
BUILDING/ PLANNING DIVISION:
Sign d App
PJB 1?34)(9) Ccs 4ityll9
Balance Due:
)7
Date