HomeMy WebLinkAboutApplicationRECEIVEr
Garfield County
GARFlELD C1. N 1 .
)MMUNJTY DEVh OPtc o mmunity Development Department
108 81h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
TYPE OF CONSTRUCTION
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
li1 New Installation I D Alteration I D Repair
WASTE TYPE
Ill Dwelling I D Tran sie nt Use I D Comm./lndustrial I D Non -Domestic
D Other Describe
INVOLVED PARTIES
Property Owner: _Steven G Haine s Phone: (_970 _)_903 -3892_
Mailing Address: _0126 Linden Circle Carbondale, CO 81623
Contractor: -Homeowner Phone: ( )
Mailing Address:
Engineer: Phone: ( )
Mailing Address :
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: _2393-284-09-012_Sub. Cooperton Townsite __ Lot 17, c_ Block 9_
Building or Service Type: _New Residence
Distance to Nearest Community Sewer System:_
#Bedrooms:~ Garbage Grinder_
~t\'
.25 miles?
Was an effort made to connect to the Community Sewer System: _N/A (Outside Town Limits)
TypeofOWTS a Septic Tank I 0 Aeration Plant I 0 Vault I 0 Vault Privy I 0 Composting Toilet
D Recycling, Potable Use D Recycling I D Pit Privy I 0 Incineration Toilet
D Chemtcal Toilet D Other
Ground Conditions Depth to 1" Ground water table j Percent Ground Slope
Final Disposal by II Absorption trench, Bed or Pit I D Underground Dispersal I D Above Ground Dispersal
D Evapotranspiration D Wastewater Pond [ D Sand Filter
D Other
Water Source & Type D Well I 0 Spring I D Stream or Creek D Cistern
l!i Community Water System Name __ Satank Water Association ltd
Effluent Will Effluent be discharged directly into waters of the State? D Yes fil No
~CERTIFICATION
Applicant acknowledges that the completeness of the application is co nditional upo-n su ch fu rther I 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 t o such terms and conditions as deemed
necessary to insure compliance with r u fes and regula t ions 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
I
further understand that any ta•sification or misrepresentation may result in the denial of the
application or revocation of any perm it granted based upon said application and legal action for perjury
as provided by law.
L ------~
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
6 /1 /r;-
OFFICIAL USE ONLY
Specfal Conditio)l.5 : _ 17.. L _L
Is5Ued w rerc re~T Cn1
Pe rmit Fee: Perk Fee: Total Fees: Fees Paid:
11'?>.Db \)(). t>O 2,; 7 ~ , c7t:) '2.,, 7 "3, DZ)
Building Permit Septic Permit: Issue Date:
~e, 1 .. 3(p 1-2-Balance Due:
BLDGDIV:_~d~~-=-=---~----J --Pf---\. __
APPROVAL