HomeMy WebLinkAboutApplication.pdfCGarfield County
Community Development Department
OCT 1108 ZD 108 8th Street, Suite 401
'6lenwood Springs, CO 81601
pAF F/E:LI.) CO (970) 945-8212
VAIU+N)TY Di:VE1: www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
iNew Installation
PE OF CONSTRUCTION
WASTE TYPE
0 Alteration
0 Repair
Xi] Dwelling
0 Transient Use
0 Comm/Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner:
Phone:
( q -7v ) 0-711—Z (-14-7 Z
Mailing Address: -717 Couhrt 1'4 1 -2. 6-2 6411c,arl
spoii.1 (-0 &/JJ/
Contractor: rc +�-- -y
ye� Phone:d
( 1 -ro i7y—z4/z i=
Mailing Address: 7 / 7 (ow) )7 1/ e" 12c gill;+
gill;
1)
SP1/4jSie-ecP40/
(
Engineer:
Phone:
( )
Mailing Address:
PROJECT NAME AND
LOCATION
-1, I J^� C 41-1 Gj Cou(Y(/ Cyv,-pKT.
Job Address: 1 Or
Assessor's Parcel Number:
Building or Service Type:..J('P
Distance to Nearest Community
Was an effort made to
2-3706 30/ C07_ Sub. F-0 (ov(r°rC efc Lot 2 Block
%y 7,)y /'- '-C #Bedrooms: .5 Garbage Grinder
Sewer System:
connect to the Community
hi i 1/ S
Sewer
System: 4./l/f
Type of OWTS
LI Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Ground water table
/1/Or Fo Percent
Ground
Slope l O o(o
Final Disposal by
lil Absorption trench, Bed or Pit
0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
0 Sand Filter
❑ Other
Water Source & Type
0 Well
❑ Spring 0 Stream or Creek
0 Cistern
p Community Water System Name
, ch i 1 r re',
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes'No
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. 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 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.
rqk�
Property Owner Print an
/ —1 4 Lf
Date
OFFICIAL USE ONLY
Special Conditions:
P���e� �
Perk Fee: �
INv,
Total 60
4/2.,
Fees Paid:
yQ�/a3. �-
Buildin Permit
elk 1-3111
Septic Permit:
't.;.-- VV.— 3L1 IF
Issue Date:Ba
10 -Zi- fit
ce Du •
.
BLDG DIV: • /D/z� 9
APPROVAL DATE
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