HomeMy WebLinkAboutApplicationte
RECD
12 2QVmmunity Development Department
108 8th Street, Suite 401
Ga 11 iLD COIN' nwood (970) Springs945-8212, CO 81601
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www.earfield-county.com
Garfield County]
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
PE OF CONSTRUCTION
IA New Installation
WASTE TYPE
Dwelling T❑ Transient Use
Other Describe
0 Alteration
0 Repair i r
To
Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: VII a i v \ \111/1
Mailing Address:
Email Address:
Phone:
) ELLE (-„,c7..-
Contractor:
Contractor:
Mailing Address:
Email Address: _
Phone: (
}
Engineer: OA 1\;\ CAM
Mailing Address:
Phone: ( _ )
Email Address:
PROJECT NAME AND LOCATION
Job Address: la CAL IID
Assessor's Parcel Number: `
Building or Service Type: V611I1r
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Sub.
Lot Block
#Bedrooms: Garbage Dispos
1(Y
Type of OWTS
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Septic Tank I 0 Aeration Plant ❑ Vault 0 Vault Privy
0 Incineration Toilet
❑ Composting Toilet
O Recycling, Potable Use
O Chemical Toilet
0 Recycling
0 Pit Privy
0 Other
Depth to 1St Ground water table
Percent Ground Slope
XAbsorption trench, Bed or Pit I 0 Underground Dispersal
0 Wastewater Pond 0 Sand Filter
0 Above Ground Dispersal
O Evapotranspiration
O Other
Well 0 Spring T ❑ Stream or Creek
0 Cistern
O Community Water System Name
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
03/22//8
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee
Perk Fee�G
Total Fees:
1703— �`
Fees Pald: Ir3
B 'Idin Permit_
135
Se tic Permit:
SRF— 51
Issue Da
11�
Balance Due:
BUILDING/ PLANNING DIVISION:
.
14 1er
Signed Approval
Date
PP. I�-3.�, >r�, 31�