HomeMy WebLinkAboutApplicationGarfield County
RECEIVED
SEP 0 3 2019
GARFIELOMMYCONSTRUCTION
COMMUNITY D - lin stallation
WASTE TYPE
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
0 Repair
❑ Dwelling I ❑ Transient Use W 10Comm.�lndustrial ❑ Non Domestic
0 Other Describe
INVOLVED PARTIES
Property _ Owner: 1 � ,��, hone:((q7Q) qaa—�t3
Mailing Address:2-1g O► ► A d y P iP ` O P\L5
Email Address: ��Pf-'J\QQ f
Contractor: -M`\ \ C') Can �[ f�C� Phone: (9W2) (e 5- ox)€
CP- - TQ► Cls
Mailing Address: A
Email Address:
Engineer:T Phone:(
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION .
Job Address: 0 y��� I, en _ 5 -
--
-_ �_�,�
Assessor's Parcel Number: L)i'y'Xrpub. t T Lot Block
Building or Service Type: CgMiYIECC'D1 #Bedrooms: 1\ d a Garbage Disposal(Y/N)
1,4
Distance to Nearest Community Sewer System: 1� R
Was an effort made to connect to the Community Sewer System: 1'] 1-#
Type of OWTS
Ground Conditions
' Septic Tank 0 Aeration Plant
O Recycling, Potable Use 0 Recycling
0 Vault 0 Vault Privy Composting Toilet
0 Pit Privy 0 Incineration Toilet
O Chemical Toilet
0 Other
Final Disposal by
Depth to 1" Ground water table Percent Ground Slope
aAbsorption trench, Bed or Pit , 0 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond I 0 Sand Filter
❑ Other
Water Source & Type
Effluent
O 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 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
hav
nowledge that I have read and understand the Notice and Certification above as well as
• Lite • he re • • ired information which is correct and accurate to the best of my knowledge.
JAL
igF/2 5
Property Owner Print and Sign
Date
OFFICIAL USE ONLY os
Special Conditions:
41,1151444 114/14/8 '014.4 ii4t411 &i rcpy4 prix, fn ac.fitR4+.e off' OeettrwA6ti.
Per it Fee: CEJ
Perk Fee:
EN
Total Fees:
1523. o°
Fees Paid: ��
lI2-
Building Permit
-moi
Septic Permit:
, 2
Issue Dat
1 1 11'
Balance Due:
.60
BUILDING/ PLANNING DIVISION:
Lithe" 10frkrief
Signed Approval
) Date