HomeMy WebLinkAboutApplicationGarfield County
RECE
Community Development Department
OCT / 9Qr 1i78 8th Street, Suite 401
enwood Springs, CO 81601
GARFIELD COUNTY(970) 945-8212
COMMUNITY DEVEtOP►W garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New. Installation _ � 0 Alteration
WASTE TYPE -- 1-11 Dwelling ` 0 Transient Use ❑ Comm./Industrial 0 Non Domestic
0 Other Describe
_ Repair
INVOLVED PARTIES �
EA�p .t)( ft Phone:( lj 7Jp'17
Property Owner:
Mailing Address: 2 2 0C, Yh i �k-A14) AO( G [ c c--0 $ ( (o
7. -- Phone:
Mailing Address: L 0 t 7 LR` 514 C W J G9
Email Address:
Contractor:
Email Address:
Engineer:
Mailing Address: 'a -01 7 LIZ 15'4 G VJ C
Email Address: 0 W.( iZ' 3 1'i G MA l L. C oft-,
O Pt E e6 a 4 OA AIL-. moi''
-fl Q.^1 Phone: ( 72) 3 C
3( (.0 i
PROJECT NAME AND LOCATION
Job Address: 9,-%- 060 a'
l �
Assessor's Parcel Number: 0 )i 6 Lk)Sub. Building or Service Type: 1`^i
�j
19&
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: h1 b T U� [ L� 13I•!
0 Vault I 0 Vault Privy Composting Toilet
-- v[
f Olr-h412 A9 Lot Block .�
#Bedrooms: —C Garbage Disposal(Y/N) �f
Jr yI-0CIL S
Type of OWTS
Septic Tank 0 Aeration Plant
0 Recycling, Potable Use 0 Recycling I 0 Pit Privy [ 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions
Final Disposal by
T1° L -t k
t 444p Other
Depth to 1St Ground water table
0 . ; Percent Ground Slope
o
O Absorption trench, Bed or Pit I 0 Underground Dispersal'
0 Above Ground Dispersal
O Evapotranspiration
Wastewater Pond 0 Sand Filter
-�-
Water Source & Type
❑ Well 0 Spring 0 Stream or Creek 0 Cistern�y
Community Water System Name - 1 14 e)' 4 7' 7�
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes kriNo
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 ar 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 ar 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.
Iv- - i8
12 y MR1 14 -
Property
Property Owner Print and Sign Date
OFFICIAL USE ONLY tpaci ��, �� NJ 4f $ C�
Special Conditions: ^-�
V g_QTre P/1-‘01-
Tota Fees:1%43 131S 13//1
Permit Fee:
Building Permit
�I
Perk Fee
Septic Per it:
F s 1L '
BUILDING/ PLANNING DIVISION:
/P
Baian e D ebo
/3 ).')--P-6
Date