HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
R F 108 8Th Street, Suite 401
Glenwood Springs, CO 81601
49C ` ? 11o, (970) 945-8212
GARFIELD COUNTY ww.garfield-countv.com
COMMUNITY DEVELOPMENT
TYPE OF CONSTRUCTION
[ New Installation
' WASTE TYPE
Dwelling I 0 Transient Use � ❑ Comm./Industrial 0 Other Describe.
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
Repair
0 Non -Domestic
III v.... V rAn....
L -Phone:
Property Owner: r-1
F- 51 L
�Phone:
!
Mailing Address: 3a6. Aiv, 3 b,-. F. 4 Co. '31 te:To
Email Address: (Li > t� . afp Q�a.41 . �O�
`.4j
' 4C3P —Li
(Az 2 La(
(60 ` j
..-S- s5
Contractor: �.
j
to ot"lei lry Phone:
'5%14- Go `) i3t 1'S
( 257
4 JS
Mailing Address: L{ t1
Z._
Email Address: ' C\ b% D c . a wry-.
JLRl
)
Phone:
Engineer:
( )
Mailing Address:
Email Address:
PROJECT NAME AND 'LOCATION
..4.0. i
Job Address: ot
v...) 1 fir'• K I L[- Ce, . Ti.„,.
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub. 5,-1r%firlectAVrel. Lot 1 `l Block
#Bedrooms: Garbage Disposal(Y/N)
Sewer
to the
System:
Community Sewer
System:
Type of OWTS
FSeptic Tank
❑ Recycling,
❑ Chemical
} 0 Aeration Plant j l 0 Vault
0 Vault Privy Composting Toilet
Potable Use ❑ Recycling f 0 Pit Privy 0 Incineration Toilet
f
1I
Toilet
0 Other
Ground Conditions
Depth to 15' Ground water table
Percent Ground
Slope
Final Disposal by
0 Absorption trench, Bed or
❑ Evapotranspiration
Pit 1 0 Underground Dispersal
0 Above Ground Dispersal
0 Wastewater Pond I 0 Sand
Filter
❑ Other
Water Source & Type
❑ Well
0 Spring
0 Stream or Creek
CC Cistern
I
❑ Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes 0 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 information which is correct and accurate to the best of my knowledge.
Pro rty Owner int and Sig
Date
OFFICIAL USE ONLY
qs; cl 10/1)}q V-14-24Qce $,-9-S.°°
Special Conditions:
Permit Fee:
1 /23. O p
Perk Fee
` /5Q. °d
Total Fees:
�-y 1�� Od
Fees Paid:id(�
`1' PG ? T3.
Building Permit
eL2r:
Septic Permit:
3E1,14 -5I' L
Issue D
IDI
e:
211 11
Balance ue�
7
BUILDING/ PLANNING DIVISION:
s/a225-1129
Sign : d Approv I Date