HomeMy WebLinkAboutApplicationDICGarfield County
Community Development Department
RECEIVED 108 8`h Street, Suite 401
Glenwood Springs, CO 81601
FEB 2 6 M (970) 945-8212
.www.garfield-county.com
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
TYPE OF CONSTRUCTION
tit New Installation 1 0 Alteration
WASTE TYPE
111. Dwelling 0 Transient Use
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Repair
0 Comm./Industrial j 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: If ( e L
Phone: ( 91D.1 q q-44— —
•
Mailing Address: • • • - , t 2
Email Address: 10i']_C 5Ala i (0"7
,){(.c.4ConSl-x-uC.F
Contractor: tA7i1N-1
-
A en
vi.4 Phone: (7 fr7 ) T59 q t4
Mailing Address: 1 i 1- 9 Hive 131 410
Email Address: .94t 1 J•1 a •s, s # r u c k :0 v1 ( • C0,1
-
Engineer: Phone: ( „)
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION--�1
'
Job Address: C.o-F
(4•� i11e. L r� Mfr,,
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub. Lot Block
y/
4',4t I:;M, I- !x•41#Bedrooms: 3 Garbage Disposal(Y/N) I
Sewer
to the
System: .4//4
Community Sewer
System: t
Type of OWTS
ritSepticTankl 1:1Aeration Plant JI 0 Vault r 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use
0 Recycling { 0 Pit Privy 0 Incineration Toilet
ii
0 Chemical Toilet
0 Other..
Ground Conditions Depth to 15t Ground water table
Percent Ground Slope
Final Disposal by
,Eh Absorption
0 Evapotranspiration
❑ Other
trench, Bed
or Pit 0 Underground
0 Wastewater Pond
Dispersal ! 0 Above Ground Dispersal
1 0 Sand Filter
Water Source & Type
❑ Well
0 Spring 0 Stream or Creek I 0 Cistern
Commun'ty Water System
daN
Name Sin fles4c +i kh
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 and Sign Date
OFFICIAL USE ONLY'2 .2Cv AV Al2. 3- oe
Special Conditions:
Permit Fee: co
`15i.3.
Building Permit
Perk Fee: v0
Total Fees: CID
Fev Paid:
CS et
13,32,- 610(0
Septic Permit:
Issue Dat 2{ I
7r, QU
BUILDING/ PLANNING DIVISION:
Signed Approval
vBalan e D e: 00
5jk/A)
Date