HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
R E CEIVE Dommunity Development Department
108 8th Street, Suite 401
JUL tJ q 2019 Glenwood springs, co 81601
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TYPE OF CONSTRUCTION
D Alteration trEL ruew lnstallation
WASTE TYPE tr Non-DomesticÉ Dwell¡ne I El Transient Use tr Comm./lndustrial-tr ottrãr Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:ü
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Phone: (c1'l(J ) <tq-ÓR{et
Email Address:
Phone:Contractor:
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Mailing Address: I
Email Address:
Engineer:Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND TOCAT¡ON
Was an effort made to connect to the Community Sewer System:
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Garbage Disposal{Y/NBuilding or Service Typel l.¿r^c\,\ fr
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#Bedrooms¡
Distance to Nearest Community Sewer System:r\,p<t-
Assessor's Parcel Number:
Job Address:
Tank!6entic E Aerat¡on Plant E Vault n vault Pr¡vy fl ComnostingÏoilet
E Recycling EI Rit erivy E lncinerationToiletE Recycling, Potable Use
E ChemicalTollet E other
Type of OWTS
Percent Ground SlopeGround Conditions Depth to 1st Ground water table
-
Absorpt¡on trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Sand FilterE Evapotranspiration E Wastewater Pond
E other
FinalDisposalby
E CisternIf.well E Spring El Stream orCreekWater Source & Type
E Community Water System Name
Effluent WillEffluentbedischargedd¡rectlylntowatersofthestate? E Yes W
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
niandatory 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 perm¡t applied for herein. I
fuither 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.
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I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
IOFFICTAL USE ONIY Ø
Special Condit¡ons:,-f
Perk Fee:f LlD. oo
Total Fees:* /T7.oo Fees Paid
$/?9. "o
Perm¡t Fee:8p?.6
Septic Permlt:
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lssue Date:
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Building Permit
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BUILDING/ PIANNlNG DIVISION:
S¡gned Approval Date
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