HomeMy WebLinkAboutApplicationGar.field Caunfii ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATIONhiAR '{ I ?0ï^Ê 108 8'h street' suite 401
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REGE ommunity Development Department
TYPE OF CONSTRUCTION
i E New lnstallation : tr Alteration Repair
WASTE TYPE
. tr o*"tt¡ne
E Other Describe
Non-Domestic
INVOTVED PART]ES
Property 6$¡¡gy¡ HES 51- Cóunty Road 222 ffC Phone, l 6fe ¡407-228;ß
Mailing Address:12433 Hwv 82 Carbondal-e,co ar623
Email Address: 1q iroux@hes-usa. com
Contractor:Heartland Environmôntal sãlviceé, l,l-c Phone:6t 407 -2280
Mailing Address:
Email Address:
L2433 County Road 82,Carbondale, Co 8]-623
lgiroux@hes-usa. com
Engineer IVIichael ,f . Camloá Phone:eJ g _) e45.2_51!__
MailingAddress: P.O. Box 1458 Glen@8L602 --
EmailAddress: mgamba@gambaengtineering. com
Ì PROJECT NAME AND TOCATION
Job Address: 51 CounLY Boad 223. nifte. CO
Assessor's parcel Number: 21-77 -1,22-00-243 ub. N/A Lot Block
Building or Service Type:Tension fabric building #BedrOOmS:Garbage Disposal(Y/N¡- N
, Distance to Nearest Community Sewer System:
: Was an effort made to connect to the Community Sewer System:no
Final Disposal by E Absorption trench, Bed or Pit Underground Dispersal E Above Ground Dispersal
E Evapotransp¡ration E Wastewater Pond nd Filter
9000 ft.
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Water Source & Type
E other
g w"ir Spring Stream or Creek E Cistern
E Community Water System Name
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El SepticTan
n iãci.line,
Type of OWTS Com iletvaultVaItpostingPlantAerat¡onk Privy tl
lncin ToierationPitUPotablesePrivyRecycling
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E Chemical Toilet E other
Ground Conditions Depth to 15t Ground water table Percent Ground Slope
Effluent Will Effluent be discharged directly into waters of the State? El Yes E ruo
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
nìândatory and addifional 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 issúance of the permit is subject to such terms and conditions as deemed
necessaì'y to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tð be submitted by the applicant are or will be repres.ented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the local
department of health in'evaluatin[ the same for purposes of issuing the permit applied for herein. I
furiher understand that anyfalsifiiation or misrepresentation may result in the denialof 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 p d the required information which is correct and accurate to the best of my knowledge.
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Prop Owner Print and Sign Date
PÞ la b"tco,Þo717, $n
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OFFICIAL USE ONtY
Special Cond¡tions:
Fees Paid:
l>z *Perk Fee:
ásø -Total Fees:lz*-Perm¡t Fee:.174-
lssue Date:
4teQ /lq Balance Due:
Ø
Build¡ng Permit
f3r n¡,F- ,Çlobt
Septic Perm¡t:
,ffiT* çIpÇ/ t
4¿løqBUILDING/ PLANNING DIVISION
Signed Approval
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Date