HomeMy WebLinkAboutApplicationftecE•►
Community Development Department
.0 108 8"' Street, Suite 401
1�L0 GO��,nwaad Springs, CO 81601
Gi,Rv `�,i aFu��. (970) 945-8212
COO www.garfield-countv.com
Garfield County
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation _ l 0 Alteration
WASTE TYPE
Igf Dwelling
0 Transient Use
l X1 Repair
0 Comm./Industrial J 0 Non -Domestic
Other Describe
INVOLVED PARTIES t _ ��II jr
01, L.��� - - Joy t-� y 14 i' tI Phone: (97O) 3 �7 9 ' /U/ _foci Ce
190 g Qo f?d G45■ fk .) ars/6;, Ci) x/(47
Jn9J 600 /r-frrx- 1. m
T13- Phone: (970 } - l !-65/6- /) ), L -i'..- (7u
Property Owner:
Mailing Address:
Email Address:
Contractor:
Mailing Address: -��
Email Address:
Engineer:
Mailing Address:
Email Address:
I317
Phone: (
PROJECT NAME AND LOCATION
Job Address: r9, )
Assessor's Parcel Number:
Building or Service Type: re-g,ditqf_,
Sub.
ne`3 Coe.) 3/404-7
W ka Lot VC. Block
Distance to Nearest Community Sewer System:
#Bedrooms: 3 Garbage Disposal()N)
Was an effort made to connect to the Community Sewer System:
Type of OWTS — » Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
❑ Recycling, Potable Use 0 Recycling 1 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other
1 E
Composting Toilet
Ground Conditions
Depth to 1St Ground water table
Percent Ground Slope
Final Disposal by
kAbsorption trench, Bed or Pit 0 Underground Dispersal f 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type 0 Well 1-0 Spring
Effluent
0 Stream or Creek
It Community Water System Name
0 Cistern
Will Effluent be discharged directly into waters of the State?
0 Yes
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.
Propert 0 ' - Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Feer
Perk Fee: �J `
�N
Total Fees:
Fees Paid:
Building rit
N I�
Septic Permit:
Se�5gG�T
Issue Dat�
GII lc\
Balance Due: 95
BUILDING/ PLANNING DIVISION:
b. P • " T^ XL 1 5
Signe Approv-
Date
pn • : oO) Cc, to 19