HomeMy WebLinkAboutApplicationGarfield County
RECEIVE
ommunity Development Department
� 108 8t" Street, Suite 401
GARFIELD COUNT'Glenwood Springs, CO 81601
COMMUNITY DEVELOPMENT (970) 945-8212
www.garfield-co untv.com
TYPE E OF CONSTRUCTION _
New Installation -
WASTE TYPE
$, Dwelling [ ❑ Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration rt�
1 0 Comm./Industrial
0 Repair
0 Non -Domestic
INVOLVED PARTIES {� +
Property Owner: -rf'� !S ! �`+'+ w i ►�'t
Mailing Address: I8 31-7 .6_ 04,6'1 kat
34rl%ee e
Email Address:
Phone: 472.A) f .2— &1. ---
«fc.? c a &dvid e. (e , (G »icz3
L. Cy. iksol
Contractor: g_z f 4- .. Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION_ ---874,2 • •
Job Address: !? 31 C 0 c ki l pe -1 l - Ion �G, r5 4€
Assessor's Parcel Number:,Z'
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
r
3 f ; ge 3d 274 Sub. LI .,v44 ke..ji 5Liii Lot Block
,� /
Q S jet.,.. £•pit ) #Bedrooms: 2— Garbage Disposal(Y/N) 1V'
Sewer System: 2 or; if S
to the Community Sewer System: /�'b
Type of OWTS
Septic Tank ! 0 Aeration Plant f 0 Vault 0 Vault Privy ! ❑ Composting Toilet
❑ Recycling, Potable Use . 0 Recycling 1 0 Pit Privy 0 Incineration Toilet
I
❑ Chemical Toilet 1 0 Other
Ground Conditions
Depth to 15t Ground water table ✓- S •r:1 Percent Ground Slope
_I
Final Disposal by
Absorption trench, Bed or Pit I 0 Underground Dispersal J 0 Above Ground Dispersal
❑ Evapotranspiration T❑ Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type
1' Well 0 Spring 0 Stream or Creek I 0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into watfirs of the State? 0 Yes 'Pt 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 hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required infor
Prop wner Print and Sig
tion which is correct and accurate to the best of my knowledge.
lc 26/
Dat
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:Total
Fees:
Fees Paid:
,,, —
Building Permit
'LSE- 5C1 H
Septic Permit
CpT -
2-
Issue Date:
q `/ PC?
Balance Due:
BUILDING/ PLANNING DIVISION:
74 '.2.131
Signed A
ro
Date
12, ,e0) Cc) l /I /t9