HomeMy WebLinkAboutApplication.pdfGarfield County
'Community Development Department
���i. 108 8th Street, Suite 401
Ienwood Springs, CO 81601
CC-1ppM ��'' (970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
❑ New Installation j 0 Alteration
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
D-4(welling
0 Transient Use
El -f ep it
1 0 Comm/Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 4"-=�.e .g- : - : Cc—
Mailing Address: ) 1 c e.
Contractor:
Mailing Address:
Phone: (,;210 )
q-70
cofLe_ Co f /f-,'-7
9�-
Phone: (
Engineer:'kee.}
Mailing Address: 33 f.,
Phone: ri7o ) 3t
`.� ed‘ (A -L6- (o 616'3
PROJECT NAME AND LOCATION
Job Address: 1 01 " [ .f- 2- i
Assessor's Parcel Number:
Building or Service Type:
Sub. Lot Block
Distance to Nearest Community Sewer System:
#Bedrooms:
Garbage Grinder
Was an effort made to connect to the Community Sewer System:
A
Type of OWTS
- peptic Tank ❑ Aeration Plant ❑ Vault 0 Vault Privy 0 Composting Toilet
1
❑ Recycling, Potable Use
0 Recycling
0 Pit
Privy 1 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1't Ground water table
3
Percent
Ground Slope
Final Disposal by
.Absorption trench, Bed or Pit I 0 Underground Dispersal 1 0 Above Ground Dispersal
(❑
Evapotranspiration
❑ Other
❑ Wastewater Pond ❑
Sand Filter
Water Source & Type
r 0 Spring 0 Stream or Creek
1 0 Cistern
❑ Community Water System
Name
/��
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes II-N6o
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. 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.
Property Owner Print and Sign
(/ (<0 (L -I
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Ts- Ud Perk Fee:
Total Fees:
Fees Paid:
Building P it Septic Permit:
3a
Issue Date: '
9- It -
Balance Due:
BLDG DIV: \i'ft- or 7--)
— 20 !
APPROV' DATE
N • S•Ppl V KA� 01- II "�