HomeMy WebLinkAboutApplicationGarfield County
Community
munity Development Department
RECEIVED
108 8th Street, Suite 401
4-/ obi e( Glenwood Springs, CO 81601
T (970) 945-8212
GARFIELD COUN w garfiefd-taunts corn
COMMUNITY ❑F.vELOPMENT
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation I 0 Alteration
0 Repair
WASTE TYPE
El Dwelling
0 Transient Use
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Laurence Bemat
Mailing Address: 968 CR 223 Rifle CO 81650
Email Address: landkhemat@skybeam.com
Phone: (Ego )625-2381
Contractor: Silt Excavation
Phone: ( ) 8760155
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 868 CR 223 Rifle
Assessor's Parcel Number: 217701200405 Sub. Antlers Orchard
Building or Service Type:
Distance to Nearest Community Sewer System: N/A
#Bedrooms: 3
Lot Block
Garbage Disposal(Y/N) N
Was an effort made to connect to the Community Sewer System:
Type of OWTS
N/A
GI Septic Tank 0 Aeration Plant
L<
O Recycling, Potable Use 0 Recycling
0 Vault
0 Vault Privy
Composting Toilet
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground Slope Essentialy Flat
Final Disposal by
Water Source & Type
Effluent
III Absorption trench, Bed or Pit
0 Underground Dispersal j 0 Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond
0 Sand Filter
O Other
El Well
❑ Spring
_L
0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ Yes m No
RTIFICATION
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.
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Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
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Permits FFee5 o�
Building Permit
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Perkfee:
Septic Permit:
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Total Fees: Fees Pald:
Issue Date:
BUILDING/ MANNING DIVISION:
Signed
Ba1ann Due:
2.7-201c7
Date
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