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HomeMy WebLinkAboutApplicationGarfield County RECEIVE Community Development Department 108 8th Street, Suite 401 GARFIELD COUNTY nwood Springs, CO 81601 COMMUNITY DEVELOPMENT �970j 945-8212 www.garfield-county.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION Property Owner: John Goss Phone: Ii. 970 ) 948.8403 If Mailing Address: k ° e '°4 Email Address: johngoss0s@comcast.net Contractor: Fisher Construction Phone: 720 ) 560.2227 Mailing Address: 122 Northway Dr, Aspen CO 81611 Email Address: TqHigher0.00m (Travis Fisher) • Alteration • Repair ❑ New Installation WASTE TYPE __.I Job Address: TBD (somewhere In the range of 4159-4283 County Rd 335) Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Was an effort made to connect . o Dwelling • Transient Use Sewer System: Yes I • Comm./Industrial Type of OWTS • Non -Domestic 0 Aeration Plant llj 0 Vault 0 Vault Privy ■ Composting Toilet ❑ Recycling, Potable Use ❑ Recycling 1 0 Pit Privy I 0 Incineration Toilet ❑ Chemical Toilet 1 0 Other : Ground Conditions • Other Describe water table Percent Ground Slope Final Disposal by III Absorption trench, ❑ Evapotranspiration ❑ Other Bed or Pit 1 • Underground INVOLVED PARTIES Property Owner: John Goss Phone: Ii. 970 ) 948.8403 If Mailing Address: k ° e '°4 Email Address: johngoss0s@comcast.net Contractor: Fisher Construction Phone: 720 ) 560.2227 Mailing Address: 122 Northway Dr, Aspen CO 81611 Email Address: TqHigher0.00m (Travis Fisher) Engineer: Kumar & Associates, Inc. (Dave Young, P.E.) Phone: ( 970 ) 384.4837 Mailing Address: 5020 County Road 154 Email Address: dyoung@kumarusa.com PROJECT NAME AND LOCATION __.I Job Address: TBD (somewhere In the range of 4159-4283 County Rd 335) Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Was an effort made to connect 218104400267 Sub. Sillivan Lot 1 Block Modular House #Bedrooms: 2 Garbage Disposal(Y/N) Sewer System: to the Community Less than 1 mile (Apple Tree Mobile Home Park) Sewer System: Yes Type of OWTS Iia Septic Tank 0 Aeration Plant llj 0 Vault 0 Vault Privy ■ Composting Toilet ❑ Recycling, Potable Use ❑ Recycling 1 0 Pit Privy I 0 Incineration Toilet ❑ Chemical Toilet 1 0 Other Ground Conditions Depth to 15t Ground water table Percent Ground Slope Final Disposal by III Absorption trench, ❑ Evapotranspiration ❑ Other Bed or Pit 1 • Underground Dispersal i I 0 Above Ground Dispersal 1 0 Wastewater Pond Sand Filter 1 0 Water Source & Type 0 Well Spring ! 0 Stream or Creek I 0 Cistern I ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? 0 Yes 0 No 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 informatipn which is correct and accurate to the best of my knowledge. Property Owner Print an Date OFFICIAL USE ONLY SIA KV/ 4/// 9 ii*"Q,5-8) •Zi 3.00 Special Conditions: *410hli 4 IVA 141M( ingtl{`afi'D ' rrwv-E ?vim, iv 6.401'44.t,4 le oeei, ,l .� Permit Feer Perk Fee: Total Fees: O00 Fees /�Paid: Building Permit Qurn-�-s9Q Septic Permit: i=.� S�P?�8 Issue Dat : i 1 �� Balance Due: Q , BUILDING/ PLANNING DIVISION: �C7�� Signed Approval Date