HomeMy WebLinkAboutApplicationGarfield County 1
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
RECEIVED
JUN 2 4 2019
GARFII
COMMUNI
jk New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
STRUCTION
0 Alteration
❑ Repair
WASTE TYPE
Dwelling 0 Transient Use
0 Other Describe
0 Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner:
Mailing Address:
Email Address: GC.IQow &A lie £/1/1i- co -r,
Contractor:_ +1[►�Q Phone: ( 7� )
Mailing Address: /J?( E 17 ST /'t N8 co $/(OSS
Email Address:
Engineer: ]P!' I 51 ll 6 t (/1? Phone: (-7(.9._) 7011r X99 /
Mailing Address: 50 al," S F 51-6,1-e /1 3 CQr be,dQl CO'3/(9`73
Email Address: lR1.sl���s�fls eh C9771
PROJECT NAME AND LOCATION
Job Address: i r{''� C
a le
/ 4-11'3 'ec h / t 4 C -a $/f .5-c
Phone: ( "170) -495-443
;es e 3- Cwt tber-C, iS fn,iC l on C a►7i
Assessor's Parcel Number: q/19,570095Sub.
Building or Service Type: 142-5/ II lciQ #Bedrooms: 3
Distance to Nearest Community Sewer System: 11
Ca T c.-8
Was an effort made to connect to the Community Sewer System:
i7 IV
Lot 1 Block_' _
Garbage Disposal(Y/N)
Type of OWTS
,a Septic Tank 0 Aeration Plant 1 0 Vault 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use 0 Recyclingj - 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Depth to 1St Ground water table
Percent Ground Slope
Final Disposal by
Absorption trench, Bed or Pit 10 Underground Dispersal
0 Evapotranspiration 1❑ Wastewater Pond
O Other
0 Above Ground Dispersal
0 Sand Filter
Water Source & Type
Well I ❑ Spring 0 Stream or Creek
O Community Water System Name
❑ Cistern
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 provided the required inforn lon wlhii is correct and accurate to the best of my knowledge.
ek fun Klein 6 211-17
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions: er0V144e
11AI
1441
Perk Fee:
Permit Fee:
/23.00
of" r'ncty i iristAi flew r imet pv i
Building Permit Septic Permit:
su E-SZI SEPT:— 5819
BUILDING/ PLANNING DIVISION:
Total Fees:
/23.00
Issue Da
te:
Signed Approval
P Iz3.O,, Ccs4i?4 I
Fees Paid: `
/ Z3. W
Balance Due:
7/17/10111
Date