HomeMy WebLinkAboutApplicationGarfield County
RV1`Vt‘tr'Community Development Department
108 8`11Street, Suite 401
Glenwood �r,t► ZOSprings, CO 81601
945-8212
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TYPE OF CONSTRUCTION
144 New Installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
'f Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Address:
Email Address:
CaA4,1 I[Yvviur A
`J\2 Com- . z : CC) t,LLSt
Phone: (ci-to) 9<<9 9( T7—
Contractor: [ iCQ L_ {til rt [ws .- s L - - Phone: ( 411 C) Stop $$ )
Mailing Address: LQ ( Z?j i'L f-•,' +f 3-• ] ►„L [1 GE-_, \5U S
Email Address: >~: i a_ (SV ( 'rn-F"'`': Cbi1eN
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: f bei C rJ :tt \ 11'0 2c-1 AVOLC ka`1
Assessor's Parcel Number: ..714. .34' ?Was b. P1'M i!S 1)y -de C xa Lot tg-1 Block
Building or Service Type: i"t.. ! jt 0i [ . #Bedrooms: Lk Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: /
Type of OWTS
Septic Tank 0 Aeration Plant 0 Vault I 0 Vault Privy I Composting Toilet
❑ Recycling, Potable Use
0 Recycling LO Pit Privy 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1St Groundwater table
Percent
Ground
Slope
Final Disposal by
0 Absorption trench, Bed
or Pit 113 Underground
I 0 Wastewater Pond
Dispersal 1
0 Sand
0 Above Ground Dispersal
Filter
❑ Evapotranspiration
❑ Other
® Well 0 Spring T❑ Stream or Creek
1 0 Cistern
Water Source & Type
❑ 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. 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.
CAA__.; :- -
Property wner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Z3 —
Perk Fee: IJr%1!
Total Fees: �
-
Fees Paid: ���
Building Permit
iM P W - 51y)Stpr-
Septic Permit:
�I 40
Issue Date.:
q--Ilq ill
Balance Due:
BUILDING/ PLANNING DIVISION:
4'
.` �qfri9116
Signed Approval Date
v9.4 m.00) Cc) 3 7-2- Ig