HomeMy WebLinkAboutApplicationCGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.eartield-county.com
TYPE OF CONSTRUCTION
OW New Installation
WASH TYPE
Dwe#lingng ❑Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
0 Repair
0 Comm./Industrial ❑ Non -Domestic
INVOLVED PARTIES
Property Owner:
Mailing Address: ' D PSeu
810-4
Phone: f S 1 , ) a.2 1 3y35 t CnSS 3(
c.165
Email Address: c.SSt .One (�r.ti�ca.\ • c M \
Contractor: Phone:( ]
Mailing Address:
Email Address:
Engineer: Phone: (I
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 4°xi1 '1, 1 -S\\ CO 1LS J
Assessor's Parcel Number: AVS. + 5L oc -7'1 Sub. ianazsecs Q-C\-4,-C\Eat- 4leek.
Building or Service Type: ? Ss62C,N- c;\ #Bedrooms +. ,q Garbage Dlsposal(Y/NI
Distance to Nearest Community Sewer System: k E�
Was an effort made to connect to the Community Sewer System: yl 1p,
Type of OWTS
C'SepticTank 0 Aeration Plant . El Vault 0 Vault Privy El Composting Toilet
0 Recycling, Potable Use 1 0 Recycling 0 Pit privy CI Incineration Toilet
Q Chemical Toilet 0 Other
Ground Conditions
Depth to 10 Ground water table ,fit 1 ec it ,ne. Percent Ground Slope °L
Final Disposal by
Water Source & Type
Effluent
Absorption trench, Bed or Pit 0 Underground Dispersal 1 ❑ Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond
O Other
b-V�rlell l Spring 0 Stream or Creek 0 Cistern
O Community Water System Name J
Will Effluent he discharged directly Into waters of the State? 0 Yes j(g No
0 Sand Filter
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional tests 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 far purpose 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 1 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.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
3I23.00
Total Feed:
j f23
Fees Paid:
SI23.00
Building Permit
BLIVI-03-20-6187
OWES Permit:
SEPT-03-20-6188
Issue Date:
v`1 / 15-7 c7Zef2
Balance Due: it
Garfield County Public Health
Department: !frSL`-( I(' -, 74- (/2,7/-11>
Signed Approve! r Data
PD. $123.00, CC. 3/18/2020