HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
RECEIVF_i.. 108 8"' Street, Suite 401
Glenwood Springs, CO 81601
FEB 1 3 2019 (970) 945-8212
www.garfield-county.com
GARFIELD COUNTY
COMMUNITY_DEVELOPMENT
TYPE OF CONSTRUCTION
Iffi New Installation
WASTE TYPE
0 Dwelling
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
SOther Describe
0 Transient Use
0 Repair
IN Comm./Industrial 1 0 Non -Domestic
INVOLVED PARTIES
Property Owner: :1/
Mailing Address: \-) O . �3 7
R
r:*�•ra.`_aPhone: (q)c.) )GLS' 359r.
- c (r), 41,C75c'
Email Address: RC'.- 5 L,,),,•ef!9 c ,,ec+. (0M
Contractor: -rn f1 d ( C I P 5.Phone: (V19 )
Mailing Address:
i lfi q p , Zmiday, Z. &15-2y
e mEoe4iiIdd sms ■ CO P14
Email Address: SAka
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
-
JobAddress: 15- 2,6 h'iy
Assessor's Parcel Number: Sub.
Building or Service Type:/,ow..wu,) Y'r4d,. ji� #Bedrooms:
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
0
Lot Block
Garbage Disposal(Y/N) /V
Type of OWTS 0 Septic Tank 1 ❑ Aeration Plant 121r Vault
O Recycling, Potable Use 0 Recycling
0
0 Pit Privy
Vault Privy n Composting Toilet
0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions
Depth to 1St Ground water table ID L.,7`
Percent Ground Slope
O
Final Disposal by 0 Absorption trench, Bed or Pit
Water Source & Type
Effluent
0 Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration
s' Other
0 Wastewater Pond
Pito-9-7/64.744.
❑ Sand Filter
O Well
0 Spring J 0 Stream or Creek
Community Water System Name
0 Cistern
Will Effluent be discharged directly into waters of the State? 0 Yes A 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.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
Total Fees:
Fees Paid:
B ilding Permit
IV 6U 15
Septic Permit:
[. 1 A
Issue Date: 6�5�2020
BalanncQce Due:
W
BUILDING/ PLANNING DIVISION:
— 6-3— 202-J
Date
Signe Approval