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HomeMy WebLinkAboutApplicationf Garfield County Community Development Department RECEIVED 108 8"' Street, Suite 401 OenWood Springs, CO 81601 (970) 945-8212 GARFIELD COWI/IN:Ka/field- countv.com COMMUNITY DEVELOPMENT TYPE OF CONSTRUCTION El New Installation WASTE TYPE ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION 0 Alteration 0 Repair 0 Dwelling 0 Transient Use El Comm./Industrial . ❑ Non -Domestic 0 Other Describe INVOLVED PARTIES Property Owner: AANZiterLt! Phone: ('' Mailing Address: 2000Bresdraty Suhe203. San F1alclsco. 0094115 Email Address: C.hatleseseharlesharrnet )77-7600 ChetteS Elter tOMlerl Contractor: nnusvk Buhl Lid, General Cawa;hng Phone: (F2O 1620-1177 Mailing Address: 7440 Deolet Street, commerce City, ca 00022 Email Address: iknmusicksilnsnecen Engineer: sGM In Ian WAiskk IGenelal Ccetraclori Mailing Address: 103 West Tcmlchl Aso Stith A r;unnlsm, CO 00123 Email Address: ter11,t1rn'.sm.lnces+n Phone: (970 ) 641-5355 PROJECT NAME AND LOCATION Job Address: 5 Qty Assessor's Parcel Number: aptitmoi Suh. Lot Block Building or Service Type: tiiu1 whirr r;nainhous9 #Bedrooms: Garbage Disposal(Y/N) Distance to Nearest Community Sewer System: 2 MI Was an effort made to connect to the Community Sewer System: N!A Type of OWTS IJ Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy Composting Toilet ❑ Recycling, Potable Use ❑ Recycling ❑ Pit Privy ❑ Incineration Toilet O Chemical Toilet ❑ Other Ground Conditions Depth to 151 Ground water table 10 Percent Ground Slope eN Finan Disposal by 0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter O Other Water Source & Type © Well ❑ Spring ❑ Stream or Creek 0 Cistern ❑ 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 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 i ules 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. 1 hereby acknowledge that 1 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. Property Owner Print and Sign tO ()'" Date OFFICIAL USE ONLY ,, Io/pi3 Oo Special Condition: Permit Fee: - Building Permits- '12)�i t0c QL Perk Fee: ENO? Septic Permit: Total Fees: CO Issue Date: 05-41.70-0Z o Fees Paid: 4)/02.00 Balance Dine}. BUILDING/ PLANNING DIVISION: Signed Approval Date