HomeMy WebLinkAboutApplication449
`j•unity Development Department
)y�Q 108 8th Street, Suite 401
QZ` ;'� ; Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
Garfield County
044
GO
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
la Dwelling
0 Other Describe
0 Transient Use
0 Alteration
0 Repair
0 Comm./Industrial _ I ❑ Non -Domestic
INVOLVED PARTIES
Property Owne _,9-
't- i x?$ P—)elA
Phone: (, q 1+-A) qa4 Z-12-5
Mailing Address: 6 C. . Si ,v 2 l Pry C i-� o r `� (D rJ L 1.)Email Address: r 4 e r L tor -co --,a [c rN
Contractor: KC3SL-s (O C r Phone: ( ? ) 2.7 L p U 1
Mailing Address: X06 12'0, 6 b r Ca I - bO cC 1P rQ
Email Address: C (C.O S 1�
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: �-I•l_,r� ��� ? /
Assessor's Parcel Number: 174 [ 2-£'l '246 Sub.
Building or Service Type: S' "`5(¢ 0'1 k"O —Q
Distance to Nearest Community Sewer System:
cc, r. rd cti
(2co-,c(NI) Lot Block
#Bedrooms: Garbage Disposal(Y/N)
7
(d s c1 c s=rcy S - 5
Was an effort made to connect to the Community Sewer System: kl®
Type of OWTS
Septic Tank 0 Aeration Plant 0 Vault f 0 Vault Privy 0 Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 incineration Toilet
O Chemical Toilet O Other
Ground Conditions I Depth to In Ground water table Percent Ground Slope
Final Disposal by Absorption trench, Bed or Pit 12 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type 4 Welli 0 Spring 0 Stream or Creek I 0 Cistern
151 Community Water System Name rt. 'cel SSyi fa, s,cL-. Lifej.,e
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes ittr No
CERTIFICATtON
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 required infjyation which is correct and accurate to the best of my knowledge.
5t
Property Owner Print and Sign
(FE41--- (.7s.4 -30-e t 0(
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
17,3.—
Building Permit- GG
Perk Fee:
f
Septic Permit:
se.pl- 524o
BUILDING/ PLANNING DIVISION:
Total Fees:
2 -
Issuai
Date: l F
Signed Approval
14D.4 213 .DD, >f lol1°I, g12o
Fees Paid:
23
Balance Due: ,,/
5/2 t/lop,
Date