HomeMy WebLinkAboutApplicationCommunity Development Department
RECEIVED 108 8th Street, Suite 401
Glenwood Springs, CO 81601
AUG (970) 945-8212
ww.garfield-countv.com
GARIFELO (COU N i
cutimmirrvrtIEVELOPMENT
TYPE OF CONSTRUCTION
New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
WASTE TYPE
Ia Dwelling
0 Transient Use
1 ❑ Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 125-L t -. -( C r -D iw1c_Ik
Phone: (9I- 0) 3' -161-- Li I V I
Mailing Address:
Email Address:
Contractor:. ��^ �5 ��� '4)014.),A Phone: ('AP 1) Loi -4'5"
Mailing Address: Lei CO- 2 c( SSt4- Co.
Email Address: Jon' ccC4 baa 0 rra3t - c Orr,
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: Sub. Lot Block
Building or Service Type: 1-x ^'4 ti,' l #Bedrooms: Garbage Disposal(Y/N)
/r
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
I I Composting Toilet
O Recycling, Potable Use
O Recycling
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
❑ Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit I� Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration
O Wastewater Pond
0 Sand Filter
O Other
Water Source & Type
Effluent
Gd Well
0 Spring
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes KI 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.
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 hereb
have p
wled - that I have read and understand the Notice and Certification above as well as
information which is correct and accurate to the best of my knowledge.
rint and Sign
Date
OFFICIAL USE ONLY
-6‘'Ndi 8/ )i 9 J a5s4 3 « 6C3
Special Conditions:
Permit Fee:
to/tee °a
Perk Fee:
r-Qc-a
Trap! Fees:
/23.0°
Fees Paid:
IS.
Building Permit
(2:12=_- saga
Septic Permit:
Issue Date
10 19
Balance
ueb®
3E 58etcl
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' �/2-.Lf
D LDING/ PLANNING DIVISION:
Ilr:.'4. - C _
Signed Approval
Date