HomeMy WebLinkAboutApplicationEC. Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 New Installation
Alteration
0 Repair
WASTE TYPE
DwellingT ❑ Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: w-,( i�R
y+ua Z,r%. -1,1.-1,1.04.1•j�Phone: (cr) ; /
Mailing Address: / 5"/3 RCQ ct 1 Cc( / f/e (c). i/SO
Email Address:
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Contractor: 0 `` ��" �k [V r c12---
/) Phone: (
Mailing Address:
Email Address:
Engineer: Phone:
Mailing Address:
Email Address:
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PROJECT NAME AND LOCATION
Job Address: NJ) )/;-P. (Q. Sr6Sc
Assessor's Parcel Number:0Sub.
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Building or Service Type: res I 1 1 (
hat .t G
Was an effort made to connect to the Community Sewer System: Nt+ um{ 0,0li„
Distance to Nearest Community Sewer System:
Lot Block
#Bedrooms: Garbage Disposal(Y/N) Nit
Type of OWTS X5eptic Tank 0 Aeration Plant
❑ Vault I 0 Vault Privy Composting Toilet
O Recycling, Potable Use
O Chemical Toilet
❑ Recycling
0 Other
0 Pit Privy
O Incineration Toilet
Gratrittondifl -- -Depth. to'1 &ound•water-table
Final Disposal by
Absorption trench, Bed or Pit
0 Underground Dispersal
O Evapotranspiration
I0 Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
❑ Other
Well
Water Source & Type
Effluent
0 Spring 0 Stream or Creek
O Community Water System Name
1 0 Cistern
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 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.
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Property Owner Print and Sign
1(R1/(awt'
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
60
Perk Fee:
(Sb . at)
Total Fees:
225: ob
Fees Paid:
Z.Zc• 00
Building Permit
Permit:
s` '.
I :: I
Issue Date:
11174111
Balance Due:
�......ehre
BUILDING/ PLANNING DIVISION:
11 2-)-2,447
Sign d Approv I Date
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