HomeMy WebLinkAboutApplicationrt Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www. arfield-county,com
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
TYPE OF CONSTRUCTION
RECEIVED
MAR / 9 7019
New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
WASTE TYPE
CTDwelling
I'Sther Describe
❑ Transient Use f ❑ Comm./Industrial
sem /�'aa.frr £ "el
0 Non -Domestic
INVOLVED PARTIES
Property Owner: f7'CSrif ,, otooe�,l Q Phone:
( )
Mailing Address: /f 2 gay / % $/ cr#t+V cua a./6,.
CD/6-()Z.
t
Email Address: d.4cjr/ 4er/GIs-;i GAM
6-
Contractor: /icy/ C 410.0 sii'(• ci4 da
( )
�Phhone:
Mailing Address: ..,--6-.0�a G 3..35- f� w 6-0,4f
' ire/6.--t7
Ik
Email Address: cf, 4 ierH4x/Civil G c,.44
Engineer: s,�►�i�/iVetv'r�•�r
Phone:
70 ) %4`fD.?//
..,4"--1,00,..r
Mailing Address: 5.0 2- incteiti firms. -$:=41. 19-...?„ [-de4dw+
h e s, �/t 2 ?
Email Address: e V t/CG! rr ei-ex' -vv/GFY-'A,7. c an -4
/9
F --1A.. 1, S�te�"+J '
PROJECT NAME AND LOCATION
�, C�ACi.c.sf-
Job Address: fid. $ don +144,+darexs
Assessor's Parcel Number.
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
2,J/$ 2 ZZ &JOa, Sub.
el / c c. , 1-..r Ad Lot 3 Block
�S t$..l«++4./
#Bedrooms: Garbage Disposal(Y/N) .4—
Sewer
to the
System: > /A4 . It
Community Sewer
System: ".0,-�d
Type of OWTS
a Septic Tank 0 Aeration
Plant
Recycling
' 0 Vault
0 Vault Privy Composting Toilet
Privy 0 Incineration Toilet
❑ Recycling, Potable Use
0
I 0 Pit
❑ Chemical Toilet
rei"Other
r r p r 21)- 1.f -412.1—AVAtA
Ground Conditions
Depth to 1st Ground water table
/O a
Percent
Ground Slopez --Ye,
Final Disposal by
0 Absorption trench, Bed or Pit
0 Underground Dispersal 1 0 Above Ground Dispersal
❑ Evapotranspiration
' 0 Wastewater
.S4 rt -if X -
Pond
0 Sand Filter
['`Other
r+�+ 4 4<.. r ,3 I`.F+o Ws r t. 1
0 Spring
Water System
Water Source & Type
0 Well
0
Name
Stream or Creek 0 Cistern
4:341 w A sy_ r,M
Ektammunity
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes Ergir
_--1 ;i• - �--
Applicant acknowledges that the completeness of the application is conditional upon 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 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 `• formation which is correct and accurate to the best of my knowledge.
Property Owner Print an • ign
0"///6 —a.? 7— 1.
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123.00
Perk Fee:
EN& .
Total Fees:
/13. 00
Fees Paid:
/2-3.00
Building Permit
1318 Pe /A—
Septic Permit:
SO RC? 676,
Issue Date
6r21?°1c1
Balance Due:
0
BUILDING/ PLANNING DIVISION:
_____
� . A '3/ 1 f l"{
Signed Approval Date
D .1./2-3.00 ,'f( /16/