HomeMy WebLinkAboutApplicationGarfield County
RECEIVEDmmunity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
GARFIELD COUNTY (970) 945-8212
[;nMMUNITYDEvELOPNEN www.garfieid-county.com
NOV 2 2 2019
TYPE OF CONSTRUCTION
rfJ IVew Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
El Alteration
0 Repair
WASTE TYPE
0 Dwelling —I 0 Transient Use TO Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 1-0 , C , V` . pe. F' h-+ o Phone: ( 9 `1Q) 3/9- 1(/ d
Mailing Address: ' . IC a
Email Address: 1 «\o ce Ate e P S a Lfi�4-
1
Contractor: _ Phone:
Mailing Address:
Email Address:
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: Sub. C0-3flF r n Lot Block
Building or Service Type: #Bedrooms: '` Garbage Disposal(Y/N)�_
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
fZI Septic Tank El Aeration Plant
O Recycling, Potable Use ❑ Recycling
0 Vault
0 Vault Privy
Composting Toilet
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Final Disposal by
Water Source & Type
Depth to 1st Ground water table
O. -Absorption trench, Bed or Pit
Percent Ground Slope
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
"Well
0 Spring j 0 Stream or Creek
El Cistern
❑ Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
❑ 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 w 'ch is correct and accurate to the best of my knowledge.
3 0 . -- C RFc J r
Property Owner Print and Sign
/l4 /Qc_/`/
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
i fir. 0 b
Perk Fee:
(St) . Ob
Total Fees:
12-1`
00
Fees Paid:
2-- 3, civ
_
Building Permit
g -e J (Do ("4
Septic Permit:
Ski! Lo'b(cf
Issue Dat:
l '1 I
, (
Balance D e:
BUILDING/ PLANNING DIVISION:
Signed Approval
Date
2 3.00) * R 7_7-
f
