HomeMy WebLinkAboutApplicationRECEIVED
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G ARF IELD
COMMUNITY D1
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OUTS)
PERMIT APPLICATION
T
%F CONSTRUCTION
Property Owner:Leal I ' aM ' Phone: (' 1► ) _ :.:2m-zigil
.
Mailing Address: (.1 • ■'- lir
Email Address: Li% i_ •! 1 r 3 1 A t
New Installation
0
Alteration
•
Repair
TE TYPE
PROJECT NAME AND LOCATION
Job Address' 'r2 C_R s75tJ%1-1 et) /h
Assessor's Parcel Number: Sub. Lot Block
Service Type: IWO...tai #Bedrooms: 3 Garbage Disposal(Y/N) %?A
-i
L'' Dwelling
0 Transient Use
Was an effort
• Comm./Industrial
:� SePtic Tank
® Non -Domestic
0 Vault
0 Vault Privy
II
Composting Toilet
❑ Recycling, Potable Use
Other Describe
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
INVOLVED PARTIES
Property Owner:Leal I ' aM ' Phone: (' 1► ) _ :.:2m-zigil
.
Mailing Address: (.1 • ■'- lir
Email Address: Li% i_ •! 1 r 3 1 A t
Contractor: Phone: (
,., J
Mailing Address: ) (4.44-,46
_D
Email Address:
ire •' 6n '16'05:1;22<y Phone: 1.)-�l6 -' . W,1
Engineer:
n�
Mailing Address: :
_ _..^
Email Address: .brC1�'Sky 0 yds tarn
PROJECT NAME AND LOCATION
Job Address' 'r2 C_R s75tJ%1-1 et) /h
Assessor's Parcel Number: Sub. Lot Block
Service Type: IWO...tai #Bedrooms: 3 Garbage Disposal(Y/N) %?A
Building or
Distance to Nearest Community Sewer System: 1 YY\ k til
made to connectecto the Community Sewer System:(.,
Was an effort
Type of ®Mins ,
:� SePtic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
II
Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Depth to 14Ground water table r
Percent Ground Slope V
Ground Conditions
—�
Final Disposal by
Ig Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
0 Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
fed' Well
0 Spring ❑Stream or Creek
0 Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes G7'�o
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 proV ed t required information which is correct and accurate to the best of my knowledge.
ffd/-z/%
v �
property Owner Print an g Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123. ao
Perk Fee: 5.Na
•
Building Permit Septic Permit:
B Iemf, (oO sept - (Oo 15
BUILDING/ PLANNING DIVISION:
Signed A .... ro
Total Fees:
123. ao
Issue Da e:
17 -
i°bO. OO) / 6lg3O(s lolls 119
Fees Paid:
123.oO
Balance Due: L r
111