HomeMy WebLinkAboutApplicationRECEIVED
OCT 18 2019 IL
GARFIELD COU T'Y-
Garfield County J
COMMUNITY DEVELOPMENT Community Development Department
108 8`r' Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.cam
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
Dwelling ❑ Transient Use I 0 Comm./Industrial
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
Lg. Alteration
0 Other Describe
❑ Repair
1 0 Non -Domestic
INVOLVED PARTIES r r
_
C 1,-:,-; s -)`int ` 3aL
.,. , ++ J`Aar�.4 .._s Phone: ( ± 2. -- 1f 1 `f
Mailing Address: _ i0 FCA41"i f Id .4 r Lv r,S Li ` /(e , Co giz -7-
Email Address: ,"7411 YF'1 arr Ll i Sr Q a-" ' Co
Contractor: riot �fe a v-jr
m
Phone: (i___) 3 q- R 414 C
Mailing Address: o o Nil
{ -e so. if eq r Ave Ca r" n J 6, / gi `o 23
Email Address: A/11tt r r race ea (14-Y1 . C (Q °mh
a- • C o �
Eng ineer: Phone. )
Mailing Address:
Email Address:
-
PROJECT-NA-
ROJECT NAME AND LOCATION
Job Address: "'j 2_0 i G i2 10 0l' a r 1.0-:,‘ r!c2 e , C., ,
Property Owner:
/
Assessor's Parcel Number: 23 ci 1I. 30h 1Y 3ub. '-"^i r- jr145 EKep.iii Lot 0-2 Block
Building or Service Type:PS: a�+l� a #Bedrooms: y Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System: Nl Pc--
r
Was an effort made to connect to the Community Sewer System: WO
Type of OWTS Septic Tank ! 0 Aeration Plant - 0 Vault 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use -1 ❑ Recycling : 0 Pit Privy 0 Incineration Toilet
f
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
C1 Chemical Toilet ❑ Other
Depth to 1st Ground water table Percent Ground Slope
ILII Absorption trench, Bed or Pit i 0 Underground Dispersal 0 Above Ground Dispersal
0 Evapotranspiration ❑ Wastewater Pond
0 Sand Filter
❑ Other
pifFNell
0 Spring
0 Stream or Creek
0 Community Water System Name
0 Cistern
Will Effluent be discharged directly into waters of the State?
0 Yes jiliko
•
PCERTIFICATION
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 information which is correct and accurate to the best of my knowledge.
?a'operty Owner Pr
OFFICIAL USE ONLY
Special Conditions:
Perm tFee:
OD
Building Permit
tit
Perk Fee:
Septic Permit:
S -IJ -.b3
BUILDING/ PLANNING DIVISION:
Total Fees:
00
Issue Da
11
Signed Approval
PD. oo) i/ 138 "2 -ft) ID I Ig t°1
Fees Paid:
Balance Due:
I 1/7/2614
Date