HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
G 108 8`h Street, Suite 401
JUL 6 6 201! lenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
El New Installation
WASTE TYPE
Er Dwelling
0 Other Describe
0 Transient Use
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Comm./Industrial I 0 Non -Domestic
INVOLVED PARTIES
Property Owner: jai n n / ru- Phone: (9 ) 7 e-(- /7
Lr . 6f.rhoyvldk c� 8/003
Email Address: 25acv i �. nRIc“ • coin
Contractor: e7 xly j V �t �lS"tty � �1 Phone: (Q ) { f gz!'T7�`
Mailing Address: Q,C� 1�-�C�_C c c`l S Set CO to
Email Address: 2434 rt it r rl141.1[ ecvkl
Engineer: Col r1,1%. C 4bed j Ni,f4c Ce SZ Phone: (940) *qe..114 - C.7-1.184
Mailing Address: ��r;3 jr4�J c ` k�C . Q . a t Ccs s/rea3
Email Address: C.[ C 0. . � �v c i i C:t� v'V\
Mailing Address: 4a q 5--lQ. p C LC k
PROJECT NAME AND LOCATION
Job Address: £2Y/ Jl Etc %Q jarick bc-. c:2 rite oeUa e Cr'; 3 3
Assessor's Parcel Number: 0915 1.33 ` PeOt Sub. � 2J fie. Lot 1 Block
Building or Service Type: a/�€`71 at,al #Bedrooms: q Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System: M 5 r -e- � A v� m
\ ► I P S
Was an effort made to connect to the Community Sewer System: DJ O
Type of OWTS
aseptic Tank 0 Aeration Plant
❑ Recycling, Potable Use
❑ Chemical Toilet
Y
0 Vault 1 0 Vault Privy ❑ Composting Toilet
0 Recycling r 0 Pit Privy 0 Incineration Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground Slope % &la/
Final Disposal by
g Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal
❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type
❑ Well
0 Spring
0 Stream or Creek 0 Cistern
Community Water System Name (5-1r)
Effluent
Will Effluent be discharged directly into waters of the State? 0 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. 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.
Property Owner Print and Sign
.1160"
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee: (�
71.
Total Fees: m0
es
Fees Paid: O
Building Permit
2112E— 481L-1
Septic Permit:
F --PT-; Lie,i
Issue Dgte:i
dtil VA:011"
Balance Due: c3°
BUILDING/ PLANNING DIVISION:
'7/1'2P17
Signed Approval
Date