HomeMy WebLinkAboutApplicationGarfield County 1
Community Development Department
NOV 1 8 2016 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
0 New Installation
WASTE TYPE
0 Alteration
GI Repair
O Dwelling 0 Transient Use
J❑
Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Michael C. Grimm Phone: ( )
Mailing Address: 6634 CR 346 Silt, CO 81652
Contractor: B&B Plumbing Phone: ( 970 ) 625-3370
Mailing Address: 1831 Railroad Ave Rifle, CO 81650
Engineer: Jefferey S Simonson Phone: ( 970 ) 945-1004
Mailing Address: 118 W Sixth St Suite 200 Glenwood Springs, CO 81601
PROJECT NAME AND LOCATION
Job Address: 6634 CR 346 Sift. CO 81652
Assessor's Parcel Number: 217916102009 Sub. Giomi Lot 6A Block
Building or Service Type: Residence #Bedrooms: 3 Garbage Grinder
Distance to Nearest Community Sewer System: Excess of 1,000 feet
Was an effort made to connect to the Community Sewer System: NIA
Type of OWTS
O Septic Tank
0 Aeration Plant
0 Vault, 0 Vault Privy
J
0 Composting Toilet
0 Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
0 Chemical Toilet
0 Other
Ground Conditions
Depth to 1 Ground water table Excess B feet 1 percent Ground Slope 1-6%
Final Disposal by
IN Absorption trench, Bed or Pit
0^n erU dd ground Dispersal 1 0 Above Ground Dispersal
0 Evapotranspiration
0Wastewater Pond 0 Sand Filter
0 Other
la Well
0 Spring 1
0 Stream or Creek
0 Cistern
Water Source & Type
0 Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes iii 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 here
have
nowle=ge that I have read and understand the Notice and Certification above as well as
ed th= equired information which is correct and accurate to the best of my knowledge.
Prop
rint and Sign
Date
It /14,.//62
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees:
Fees Paid:
Building Permit
Septic Permit:I
"II
Issue Date:
Balance Due:
BLDG DIV:
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APPROVALdill
DATE
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