HomeMy WebLinkAboutApplicationPC Garfield County
Community Development Department
RECEN698 8th Street, Suite 401
Glenwood Springs, CO 81601
MAR 7 2 2019 (970) 945-8212
(3ARFIELD C0www
UMINUNITY DEVEL OPZL
TYPE OF CONSTRUCTION
New Installation ^,
E TYPE
Dwelling 0 Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration �,- L ❑ Repair
7 ❑ Comm./Industrial
Non -Domestic
INVOLVED PARTIES
Property Owner: 7
Ze),�,1 Phone: ( ) --
Mailing Address: /4! �V� (4IL (1 - , 0 0/6 01
Email Address: - CW/r/720/7/a5 /7_0
Contractor: �7/ .5,17-i/Cf7orf 17'-% G Phone: {4Cr % �� ,
Mailing Address: /2T )ne e4 -7e. f .S71717 Cc 6/0 5-z•
Email Address: , J (il-V rilei-7�9102)7 a c!thct1I
Engineer: e Phone:
Mailing Address: O C; Xi I Si 6611GLecid c /59/00/
Email Address: 4pi i eueoci.j 4177a vi (asG4 , C(on/
PROJECT NAME AND LOCATION
Job Address: 17:3z5r"
vo _0s aJOrreh d/
Assessor's Parcel Number: n-3 w ' 6 _ Sub. f Lot
#Bedrooms: 3 Garbage Disposal(Y/N)
S --)(7016
vice Type: 1/ • -i,7 .�I
BI dt k
(-71 /Vo '/037
Distance to Nearest Community
Was an effort made to connect
Sewer System:
to the Community
4619-tA/
f
Sewer System:
/mai-//C44/
Type of OWTS
Septic Tank
I 0 Aeration Plant 0 Vault 0 Vault Privy Composting Toilet
I
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
[ 0 Incineration Toilet
I
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to lst Ground water table
' Percent
Ground
Slope
Final Disposal by
)Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
0 Evapotranspiration
0 Wastewater
Pond f
L
0 Sand Filter
❑ Other
Water Source & Type
Well
0 Spring
0 Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes
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 pxovideh equi red information which is correct and accurate to the best of my knowledge.
Property Owner P int and Sign i ra Date
—1/ /7
.____ u 11
OFFICIAL USE ONLY
Special Conditions:l
PN?i>I+I.G[�vv -APIA 91)4A:ho lel moi' p°r by 'th fifrtAI I tri?. iiem 4f c. 0 .
Permit Fees
4
Perk Fee:
F
Total Fees:
1 /23.6p
Fees Paid:
1/2-S . oo‘
Building Permit
�E.-342[08
Septic Permit:
S 9
Issue DaBaianc
31161
Due:
•60
BUILDING/ PLANNING DIVISION:
fa
4 /
/141q
Signed Approval Date