HomeMy WebLinkAboutApplicationGET\j4v
1 %OS
u S nity Development Department
GO lino- 108 8th Street, Suite 401
Gog-‘00m ❑F'iE4 Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
Garfield County
coo
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
ja Dwelling 0 Transient Use
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
XAlteration
0 Comm./Industrial
Repair
0 Non -Domestic
INVOLVED PARTIES
yt n
S1 ig,9 C1L ->' / 2oa�
Property Owner:
Mailing Address:
Contractor:
Mailing Address:
-37 - 2 LV 7
Phone: (6\10 )
I O' @Arr. N 0 61Cp
Phone: ( ) 3u 2.3
Engineer: Phone: (
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: ‘-3
Assessor's Parcel Number: 23 t r t c1 `- ) s
t cr
Lot Block
Garbage Grinder
Building or Service Type: RE Nt VAL. #Bedrooms:
Distance to Nearest Community Sewer System:
Was an effort made to con ect to the Community Sewer System:
Type of OWTS
Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Depth to 15` Ground water table
Percent Ground Slope
Final Disposal by
Water Source & Type
O Absorption trench, Bed or Pit 0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration I 0 Wastewater Pond
0 Sand Filter
❑ Other
Well
0 Spring 0 Stream or Creek
0 Cistern
O Community Water System Name
Effluent 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. 1
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 r= ' uired iforigr+ which is correct and accurate to the best of my knowledge.
Property
I/
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Is 00
Perk Fee:
(D W
Total Fees:
2 . Do
Fees Paid:
27.-S1 Dry
Building Permit
Septic Permit:
Issue Date: i I
Balance Due:
BLDG DIV: "Mrr.���.__.
APR AL
! 7
• ,0
2' 2c) C/
DATE
1
PD 2ZS-tom, d 3os3� 1-111-- lo)