HomeMy WebLinkAboutApplicationGarfield County 1
�.j Community Development Department
F n'ti 4,� 108 8`h Street, Suite 401
.601
% DEQ;dienwood Springs, CO 81601
AN' (970) 945-8217
�atA
pf www.garfield-county.com
to TY E OF CONSTRUCTION _
l2New Installation
_
WASTE TYPE
Dwelling I ❑ Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
—� ❑ Repair
D Comm./industrial 0 Non -Domestic
INVOLVED PARTIES l _
Property Owner:4E14-0 –S#M 1'!/'mss t' Phone: (Gj O ) 3/ 9 -R49.
Mailing Address: J 57.2 ( AO) WOO} ve £) / i A gift se
Email Address: e.50 --V ('r%' z X el &� 9 frZJ J e'[-Gf 7
Contractor: Al - 4-'S 4 Qom- Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: T%t)
Assessor's Parcel Number:A 79 0 99600Aub. iv /4- Lot 4J/4 -Block ,u.'/
Building or Service Type: j&SJ n lci #Bedrooms: •- Garbage Disposal(Y/N) !J
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: n _l
.J % 4
Type of OWTS
Ground Conditions
Final Disposal by
'SepticTank I 0 Aeration Plant
❑ Recycling, Potable Use
O Chemical Toilet
0 Vault 1 0 Vault Privy L ❑ Composting Toilet
0 Recycling I 0 Pit Privy [ ❑ Incineration Toilet
0 Other
Depth to 1g' Ground water table
1" -Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal
0 Above Ground Dispersal
❑ Wastewater Pond
0 Sand Filter
0 Other
Water Source & Type well
0 Spring
0 Stream or Creek
0 Cistern
O 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 cuch 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.
Propert Owner"Print and Sign
Oy /7-/�
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
li3 OD
Perk Fee:
1W. o0
Total Fees:
2 7-3•OD
Fees Paid:
2-33. o -o
Building Permit
>A- 1.-2-2
Septic Permit:
SFr— 51-23
Issue Date-
5 f 3 )!6)
Balance Due:
BUILDING/ PLANNING DIVISION:
PA/1/0--•iT r5/2/v izT
Signed Approval Date