HomeMy WebLinkAboutApplication°\1,v ( . Garfield County
0- �v '��``'Coirinunity Development Department
,..004 ct 108 8th Street, Suite 401
R00.9
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to q*�rc�0 Glenwood Springs, CO 81601
��► VN1 (970) 945-8212
CSO
www.garfield-county.com
TYPE OF CONSTRUCTION
• New Installation
WASTE TYPE
O Dwelling
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Transient Use ❑ Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Jose m ruiz martinet
Mailing Address: f (5 rlr ave rifle CO ii1 bbU
Email Address: miKe.unicorp(CUgmaII.COm
Phone: (9 t-U-Sil 9:9J353
Contractor: Owner Pulia
Phone: ( )
Mailing Address:
Email Address:
Engineer: H'F' Kumaran-a P►SS6C1al S
Mailing Address: SULU COUntY KOaa "I 54
Phone: (97 -U -»b
Email Address: KCrisier(CUKUmarusa.COm
PROJECT NAME AND LOCATION
Job Address: 19 native springs drive rifle CO
Assessor's Parcel Number: Sub. Nativ.e springs Lot I Block _
#Bedrooms: b Garbage Disposal(Y/N) n0
Building or Service Type: resiaentiai nome
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
-Type of OWTS O Septic Tank I 0 Aeration Plant 0 Vault I 0 Vault Privy ❑ Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy J 0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to l' Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit
O Evapotranspiration
0 Underground Dispersal
0 Above Ground Dispersal
0 Wastewater Pond { 0 Sand Filter
O Other
Water Source & Type
Effluent
O Well
0 Spring
0 Stream or Creek l 0 Cistern
O Community Water System Name
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 which is correct and accurate to the best of my knowledge.
1i
Property Owner Print an• Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
12 3 . oo
Perk Fee:
ENG.
Total Fees:
123. oo
Fees Paid:
/23.00
Building Permit
relt-n-51
Septic Permit:
%?f- 5111
Issue Date:
n.q.lP
Balance Due:
0
BUILDING/ PLANNING DIVISION:
2e^6
4t92 5/4/2e16
Signed Approval Date
pp.fiv,.vo cc, '4,r 3 It