HomeMy WebLinkAboutApplicationCGarfield County
RECEIVEDCommunity Development Department
108 gth Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
GARFIELD COUNTY www.garfield-county.com
COMMUNITY DEVELOPMENT
MMI £�I�
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Alteration
Ni Dwelling 0 Transient Use 0 Comm./Industrial
0 Other Describe
0 Repair
0 Non -Domestic
Avtd6".'
INVOLVED PARTIES
Property Owner: o� ��4-ryf-ti
�^ ,j Phone: (C110 ) 1O(j 02 -SS
Mailing Address: 1 2 -it d lt Rd 100 Ccu bNcaakt.1 alu�3
Email Address: rOd G) parcu}DgCf.. COM
Contractor: ROSS T 11V, OV , �l Phone: (110 ) 3 , ` ' r169
Mailing Address: SAO C0.CkAS iici S RC1 Crb8vtdale, CO 3 ((2 3
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME ND LOCATION`�r�,tO CKtoo CArI o (a(c, Co
Job Address: y 1LCSDU �a��de(4 tZ
Y �A1�� toh g10—,
Assessor's Parcel Number: Sub. Lot Block
foss rx7 kov04. c-aV&ioly. Com
Building or Service Type: St (A,
#Bedrooms: "' Garbage Disposal(V/N)
Distance to Nearest Community Sewer System: 0.4-VOWll\
Was an effort made to connect to the Community Sewer System: N 0
Type of OWTS
) I Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
❑ Composting Toilet
0 Recycling, Potable Use 0 Recycling • Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to 1st Ground water table Percent Ground Slope
kAbsorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Final Disposal by
Water Source & Type
Effluent
Well
0 Spring 0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
0 Yes No
CERTIFICATION
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 ac owledge that I have read and understand the Notice and Certification above as well as
have = ovi d the :r'".'red information which is correct and accurate to the best of my knowledge.
Owner Pr t and Sign
1:7
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
'0b
Perk Fee:
I5b . DD
Total Fees:
lay. DD
Fees Paid:
Z7 -S-7 D O
Building Permit
GA -PA- 33-12
Septic Permit:
S pi--- 51-(0(0
Issue Date:
- -.-- ,
Balance Due: ,
95
BUILDING/ PLANNING DIVISION:
I 7
1 Ilk ,
3i►�' 6*247
Signe. • . . r.val Date
D. 7,7,S: co) V (O3o) 5f2-1)11�