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Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www,garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
I ❑ New Installation
3151/(ASTE TYPE
Dwelling 1 0 Transient Use
❑ Other Describe
' 'Alteration
0 Repair
0 Comm./Industrial 1 0 Non -Domestic
INVOLVED PARTIES [ _ne: .-- �r
Property Owner: ' �i i t� `^ g- ( �' V 'j' -1 / 03 `f 1 -
Mailing Address: (if 61 U C(.•- .- w
Email Address: q l +W}.l1 - 1'r^ p"ti e- ----
Contractor: KVA. ' Phone:
Mailing Address:
Email Address:
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Engineer: k•+
- if) Lai
Phone:
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Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 1 Cb 0 C- 0— 1 a 1
Assessor's Parcel Number: 2.31 I Z (-(12 t 0•0-��1 L � Block
iPv D it
Building or Service Type:
#Bedrooms: f. Garbage DisposatON)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Tr Septic Tank 1 0 Aeration Plant
0 Vault
0 Vault Privy
❑ Composting Toilet
O Recycling, Potable Use
O Recycling
0 Pit Privy L 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Ground water table
Percent Ground Slope
Final Disposal by
Rt Absorption trench, Bed or Pit
0 Underground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
Water Source & Type
Effluent
O Other
❑ Well 1 ❑Spring 0 Stream or Creek [ 0 Cistern
I
T;fi. LI(.l- 5 eulr
Will Effluent be discharged directly into waters of the State? 0 Yes deNo
Community Water System Name
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 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
Fog of A/Y-L, -) &vi f=]
Fees Paid:
Perk Fee: 0
Septic Permit:
Total Fees: s
Th
Issue Date:
(01101149
BUILDING/
BUILDING/ PLANNING DIVISION:
PD -1-S.co) tL t 1p Ik)k
Balance Due:
Date