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Garfield County
GARFIELD CORFr unity Development Department
)MMUNITY DEVELOPMENT108 8`h Street, Suite 401
enwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
lid New Installation
0 Alteration
0 Repair
WASTE TYPE
tgi Dwelling 0 Transient Use 0 Comm/Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Klfeit skivi. r e Q.ill iotts
- 7]
Mailing Address: 31 [.ordinal Smit\ C— RIL 01
Contractor: ] (1,A141LA(S t;, { Phone: (Q7[D } q151700 — 2c)2S
Mailing Address: ) C.Ii.tl hnv ,tom, LA. N L.s Ccis-Ht Co R 1 LLA
Engineer:
i Phone: ( 470 )ICY —S) S 4
Mailing Address: V Frx.tr \jn.e.t (+Dr. C.nr6on-L k CO$1Loz'z,
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number:.2vg32yl2DipoiS Sub.
CGUUir04+. konr.L Lot iC Block
Building or Service Type:#Bedrooms: .3
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Garbage Grinder
Type of OWTS
Ground Conditions
PI Septic Tank 0 Aeration Plant 1_0 Vault 0 Vault Privy 0 Composting Toilet
0 Recycling, Potable Use 0 Recycling 0 Pit Privy 1 0 Incineration Toilet
__1 z
O Chemical Toilet 0 Other
" Depth to 1' Ground water table i emi•er ` Percent Ground Slope 5 ,g
Final Disposal by Absorption trench, Bed or Pit 0 Underground Dispersal j 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
.0 Other
Water Source & Type 0 Well 0 Spring ' 0 Stream or Creek 1 0 Cistern
ii Community Water System Name rytc
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes Et 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
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
1Z3.00
_.---ILILr
x`1)15
Date
Building Permit
gi?E- 331-3
BLDG DIV:
Perk Fee:
— - eiN4-.
Total Fees:
17-3* 00
Septic Permit:
SE1i 3f--I-
Issue pate,
'El (r it
Fees Paid:
123.00
Balance Due:
0
7 z9 ,5
DATE
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