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1 ,. Gar.field County
JAN 3
Communiw Development Department
GARFIELD COU~ios 8th Street, Suite 401
MMUNITY DEVEiG ~~wood springs, co 81601
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
(970) 945-8212
www.garfleld-countv.com
PERMIT APPLICATION
TYPE OF CONSTRUCTION
D New Installation I D Alteration I l8C Repair
WASTE TYPE
D Dwelling I D Transient Use I a Comm/Industrial l Cl Non-Domestic
Cl Other Describe
INVOLVED PARTIES
Property Owner: 1-1/J YI EAJ :EAJ IJesrAeAJ ~ :z;ik_phone: ( 'i_70 ) 46 'I-/tl 'j'(
Mailing Address: P,o. ~ox /00 P elis·~<!.-,{; lo f1S-~fo
Contractor: J..I. .z: RZIJ£L Cl2.N s r ,ew c:.:rZ o .'1/ Phon e: ( 9 70 ) 02, 5 ~ -/S"S'o
Mailing Address: L5SI._ 4),, z::;.,d ~tl,<.-,J c....,r-i &ri:.r1 J ~" ...+,-o,,., {o 81 ws--
1
Engineer: -r-i.I(}~ c; c,. LL . r rO ... /-c Phone: ( 2 70 ) d. l/ s--0 S' I")/]
Mailing Address: t..I ~ 7 oJ '1 RQc,,/ f.>.rc.,..,c:J ~,,,J.-o...., t. lo !IRJS-
'
PROJECT NAME AND LOCATION -
Job Address: tn / 93 i!.~cl.s 1 .. 1 c ....... /-'c.rr. c.,./,.,k -f-c., /o e11.,s~
I
'-/ Assessor's Parcel Number: (;).'{ 0 9.) '7 3/0 Ool./ Sub. ":5 frc '1J-s '-b Lot Block --
Building or Service Type: L_ol-'>1~ #Bedrooms: Garbage Grinder _
Distance to Nearest Community Sewer System: &.4
Was an effort made to connect to the Community Sewer System: A/4 Ve..s
Type ofOWTS fl Septic Tank I a Aeration Plant I a Vault I Cl Vault Privy I a Composting Toilet
Cl Recyding, Potable Use Cl Recyding I Cl Pit Privy I Cl lndneratlon Toilet
C Chemical Toilet D Other
Ground Conditions Depth to 1" Ground water table 1..0" j Percent Ground Slope ..;)-3 O/~
Final Disposal by I{ Absorption trench, Bed or Pit I D Underground Dispersal I D Above Ground Dispersal
Cl Evapotranspiration D Wastewater Pond I Cl Sand Filter
C Other
Water Source & Type IS Well I D Spring I Cl Stream or Creek I a astern
Cl Community Water System Name
Effluent Will Effluent be discharged directly Into waters of the State? Cl Yes Jl'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 information which is correct and accurate to the best of my knowledge.
f?.•<J ,,f.,7 J<.Vl ~R'--F~o-1.s
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Perk Fee: To~Fees: §9 FeesPald: ~
1~·00
Permit Fee: CfJ_ $ ;:.--
Ba_!¥ce Due:
~~j!D_
Issue Date:
I--:-0-2ofi
DATE