HomeMy WebLinkAboutApplicationRECEIVED
Garfield County
Community Development Department
GARFIELD COUNTY 108 8'h Street, Suite 401
COMMUNITY DEVELOPMENT Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
III New Installation
WASTE TYPE
I3 Dwelling I ❑ Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
1 0 Alteration
❑ Repair
0 Comm./Industrial I 0 Non -Domestic
INVOLVED PARTIES
Property Owner: _Atari Ca rcie oCS
Phone: ( mac) 2-1 LI
Mailing Address: 21 , 5 -1-kw y LQ 21,1 # wog 12 -i'i e
Email Address: Ca r-ci.E r-, 4S _ l e ¢Gl es tci - c rr
G O S''1 (o S-O
Contractor: f IC(.1) o t: x r cN v c H s-)
Mailing Address:
Phone:()cjy$ •`ii 7_2_Le
Email Address: i2ui 2 C 5O P'rl3 ' nE 1
Engineer: MI c.hca i 5• V i I l.e i l c
Mailing Address: PO r X 21 1-1 rd S CA
Phone: (criC1 ) 30 tG'—I 1/40
$ILA32
Email Address: in; kej0 On €rl e `ii 1 111 +. cx s lr r c_ o ¥ V
PROJECT NAME AND LOCATION
Job Address:
Assessors Parcel Number: Sub.Svv% Mtai1 W C44-4ot .19 Block
Building or Service Type: TZ-(&) er. -J A_) #Bedrooms: Li Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
iJ
Type of OWTS
Ground Conditions
Final Disposal by
❑'Septic Tank 1 ❑ Aeration Plant I ❑ Vault ' ❑ Vault Privy i ❑ Composting Toilet
— — .I.
l] Recycling, Potable Use {1 0 Recycling • 0 Pit Privy 1 0 Incineration Toilet
O Chemical Toilet 0 Other
k
Deth to 10 Ground water table
1
Percent Ground Slope
Absorption trench, Bed or Pit 0 Underground Dispersal t 0 Above Ground Dispersal
O Evapotranspiration I 0 Wastewater Pond 0 Sand Filter
0 Other
Water Source & Type krWell
Effluent
0 Spring
0 Stream or Creek 0 Cistern
Will Effluent be discharged directly Into waters of the State? 0 Yes
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.
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.
1j O k
Property Owner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
fi3.00
Building Permit
131,1zt - 6115
itszkierim
Septic Permit:
SE'r- ('III,
BUILDING/ PLANNING DIVISION:
Total Fees:
Issue Date:
►Z3. oo
7
Date
Fees Paid: 1233. op
Balance Due: d
Signed Approval`
1'D.$13-3.00) CC., 311117.oz o
0 `(/ /Ze c2
Date