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HomeMy WebLinkAboutApplicationre Garfield County Community Development Department 108 8th Street, Suite 401 RECEIVM3Inwood Springs, CO 81601 (970) 945-8212 AUG 3 0 2Q Ivww.garfield-county.com GARFIELD COUNTY COMMCOMMYlikroVECOiM RUCTION New Installation WASTE TYPE r� Dwelling 0 Transient Use ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION 0 Alteration 0 Repair 0 Comm./Industrial 0 Non -Domestic 0 Other Describe I -INVOLVED PARTIES Property Owner:G� �Ar•T/E �c �dF & Phone: (5A7 ) Mailing Address: _/„20 9 / C J 5 O 4I`+ % (0 (3-J e Email Address: -2-167 ,4.9 7/E/" ids 6 iP/L . �r�I Contractor: .ems ��6�,c�f%/� -USt T.r Phone: (7) ) Mailing Address: I Email Address: /G$G4)7t //d�7-G'd 1 23i4 / Engineer: 7Cf'Er / S . 6,- ,05o,cVkind !'-7 Phone: ( Mailing Address: SG1/' 7 Email Address: PROJECT NAME AND LOCATION 7 Job Address: .e/1� r i) e f ,t2 2) CIi51LE Assessor's Parcel Number: Sub /Ee44 6r1 'vs Lot 2 Block Building or Service Type: /rc)6 Cc- 2 `-4/// tiBedrooms: r' Garbage Disposal(Y/N) Distance to Nearest Community Sewer System: Was an effort made to connect to the Community Sewer System: Type of OWTS Ground Conditions Final Disposal by Water Source & Type Effluent O Septic Tank 0 Aeration Plant O Recycling, Potable Use O Chemical Toilet 0 Vault 0 Vault Privy O Recycling 0 Pit Privy ❑ Composting Toilet 0 Incineration Toilet 0 Other Depth to let Ground water table O Absorption trench, Bed or Pit O Evapotranspiration Percent Ground Slope 0 Underground Dispersal O Wastewater Pond 0 Above Ground Dispersal 0 Sand Filter O Other O Well 0 Spring 0 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 Si /, Date OFFICIAL USE ONLY 4.43.1d V30 00 8 I I(D3 31 3. ©6 Special Conditions: Permit Fee: 7'r-23. °O Perk Fee: . ca Total Fees: /.2.3.°O Fees aid: 7 3 °o Building Permit PE-- Septic Permit:Issue ���� 5L i_.Z_J D te: 10 `111% Balance Due: `flo . . BUILDING/ PLANNING DIVISION: . �I ,F,,,,..- 1/27 (9003 Signed Approval Date