HomeMy WebLinkAboutApplicationGarfield County
RECEricivrunity Development Department
108 8th Street, Suite 401
Sr) 2014 Glenwood Springs, CO 81601
(970) 945-8212
GARFIELD COUNTwYww,earfield-county.com
COMMUNITY DEVELOPMENT
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
O Dwelling 0 Transient Use 0 Comm./Industrial
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Tom and Leann Jurmu
Mailing Address: 995 County Road 229, Silt, C081652
Email Address: tomjurmu@gmail.com
Phone: (970 ) 319-3211
Contractor: Same as above
Phone:(
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:
995 County Road 229, Silt, CO 61652
Assessor's Parcel Number: 217905101003
Building or Service Type: New
Sub. Dutch Major
Lot 3 Block 1
#Bedrooms: 5 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS ® Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy Composting Toilet
0 Recycling, Potable Use 0 Recycling
0 Pit Privy 0 Incineration Toilet
O Chemical Toilet 0 Other
Ground Conditions Depth to 15t Ground water table Percent Ground Slope
Final Disposal by
❑ Absorption trench, Bed or Pit 0 Underground Dispersal 1 0 Above Ground Dispersal
❑ Evapotranspiration [ 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type El Well ' 0 Spring 0 Stream or Creek 0 Cistern
O Community Water System Name
Effluent
icxpej
Will Effluent be discharged directly into waters of the State?
CIS �#tw
arckl; hb, t 1 a�►+�
❑ Yes M No
19 r - ' "vs+
4t eC i ha.>J•L ciA0L-
.•.-Ce AKS e k+e J. y off- .‘. -iCe i& '&J Ke C€ ‘1.1 ���►.
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
hav provided the required in
3.lkr4tA LA-
Le -A•. 3
Property Owner Print and Sign
ation ' hich is correct and accurate to the best of my knowledge.
Date
OFFICIAL USE ONLY
1
Special Conditions: 4�iet, +ink 4 �;��,44 � AGAO►r1w I4 - O� i+LOWA1 1,4v -zoos A+
NA W31404,4- ihc-iL'tior fitgG at uti{;vash4d late) anth+t.
Permit Fee:
1-.. 0 ,
Perk Fee:
h Pei,
Total Fees:
6 ), • r
Fees Paid:
9-5 ®A
Building Permit
D - 561461
Septic Permit:
Cb pr- 56150
Issue Date:
10 -fit -19
Balance Due:
PLANNING DIVISION:
MP
0,! '1 10/1b/11BUILDING/
Signed Approval Date
1'1)4 00) CC,) ' 13 I'q