HomeMy WebLinkAboutApplication09/04/2015 11 06 FAX 9709257341
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RECEITVFI.
SLP 12,
GARFIELD C(
)Mt, UNITY DR E.
Garfield County
Community Development Department
108 8'h Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8222
www.earfield•county.curn
01 251441 pion 05.04. 201S
ONSITE WASTEWATER
TREATMENT SYSTEM
(Q'') _..
PERMIT APPLICATION
YYPE OF CONSTRUCTION
X New Installation - ❑ Alteration--�..._ ❑ Repair
WASTE TYPF
Dv: el 0 Transient Use
0 Comm./Industrial I 0 Non -Domestic
O UtIwr Litscr
INVOLVED PARTIES
Property Owner: kiwi c, - Sc+ u
Mailing Address:,
Phone: ( 97 0 ) z.39?
/21111 35- 7/=71$ >JJ wa C.t..4 1/ti cc- 8/6/7
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Contractor: �_.�r'1r�7�`t�a1�L-0,1 - - Phone: ( 9 e. ) $(.45 -
Mailing Address.
Engineer: Phone; (
Mailing Address;
PROJECT NAME AND_ LOCATION `�T
•
lob Address: i'�3D C`lt�; rk - 7': r° k,�.t� .,L:- �a. - to 91G ra --
Assessor's Parcel Number: 3,17 j.2.?/dl -eez. Sub. .$s
r I.:/N. r Cr Lot �- Block
Building or Service Type: 'IC-/r'I rrf-�-(`c r .tib #Bedrooms: _3 Garbage Grinder ,
Distance to Nearest Community Sewer System: /0—i S ri. e5
Was an effort made to connect to the Community Sewer System: Aii
Type of DWI'S
-- ' Septic Tank 0 Aeration Plant j 0 Vault L0 Vault Privy lI ❑ Composting Toilet
l7 Reryeltn, Potnhle Ilse .i l Aeryding.I 'ifPit Prlvy 1 1a InCinerationTolEet
O Chemical Toilet I 0 Other L
Ground Conditions Depth to ft Ground water table I Percent Ground slope
Final Disposal by
❑ Absorption trench, Sed or Plt 0 Underground Dispersal ❑ Above Ground Dispersal
O Evapotranspiration 1 0 Wastewater Pond I ❑ Sand Flltcr
O
Other
Water Source & Type lX,WeIi j 0 Spring ❑ Stream or Creek 0 Clstcrn
❑ Community water System Nome
Effluent Will Erfiuent'be discharged directly Into waters of the State? 0 Ire.
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09/04/2015 11 06 FAX 9709257341 0003/005
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CERTIFICATION
! Applicant acknowledges that the completeness of the appTCatian i5 Conditional uppii such further��
mandatory ,Intl addit'onal tec,t and reports as may be required by the local health cepartnient to be
made and furnished oy the applicant or by t.te local health department for purposed of the evaluation
of the application, ar d the issuance of the permit is subJoct 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 ar misrepresentation may result In the denial of the
application or revocation of any permit granted based upon saidapplication and legal action for perjury
BrDu rie;tl by aw
I hereby acknowledge that 1 have read and understand the Notice and Certification above as well as
have p Ided there ed Information which Is correct and accurate to the best of my knowledge.
tel c,t
(3/61
erty Ownor Print and Sign Date
OFFICIAL USE ONLY -
Special Conditions:
Permit Fee:
1g3.I%
Pork Fee:
Ic-ti•ao
^
Total Fees:
273- ad
Fees I';tld:
7-1-- 4506
Ruirdlnr Pewit I/��
r � rl
ycr tic Permit:
3<13
hie a: C
13bl IS
P'—
Galante Dur.:
`/Z
MG bIV: /-12.4e.
1
APPROVAL. DATE