HomeMy WebLinkAboutApplicationIREG lII
��rimmunity Development Department
SAN 1 ID 1 8 8t" Street, Suite 401
l�L� GpIJll�elwoad Springs, CO 81601
�,ARutyir[ ❑f.VE P (970) 945-8212
COMA www.garfield-countv.com
Garfield County
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation
TYPE
0 Alteration
llY
Repair
Dwelling 1 0 Transient Use
0 Comm./Industrial
O Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: fjj0 Est t
Mailing Address: r
Email Address: it, if 13
1 Phone: (
Contractor: A 1 Okra ( �1 r & C Atj 141-t'11 M Phone: ( (TIO )
Jay
Mailing Address: ) Fox: /I (� SL C_T Ct c-616 5 z -
Email Address: U S7 J t7 44-0g OA f iic e e ►4L!_►=ETI' 1 e_T
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parce
Building or Service Type:
Distance to Nearest Community Sewer System:
11074
I to to
Sub. Lot Block
#Bedrooms: Garbage Disposal(Y/N)
Was an effort made to connect to the Community Sewer System: jL
l;
i.
Type of OWTS
El Septic Tank I 0 Aeration Plant j 0 Vault ❑ Vault Privy f
❑ Composting Toilet
O Recycling, Potable Use 0 Recycling ❑ Pit Privy 0 Incineration Toilet
O Chemical Toilet
O Other
Ground Conditions
Depth t 1St Ground water table Percent Ground Slope
Final Disposal by
Water Source & Type
Absorption trench, Bed or Pit
1 0 Underground Dispersal
0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Cf/Well I 0 Spring 0 Stream or Creek
O Cistern
O Community Water System Name
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. 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 an ' ign
/t J!
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee: 6
Total Fees:
Fees Paid:
Building Permit
Se tic Permit:
—e&a''_
Issue Date:
I_ IU,—It
Balance Due:
BUILDING/ PLANNING DIVISION:
�i
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1— I"'r_ 20/6
...
Sign : . Appro I Date
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