HomeMy WebLinkAboutApplicationGarfield County
1171- Inoio :T"Community Development Department
108 8th Street, Suite 401.
Glenwood Springs, CO 81601
(970) 945-8212
www.earfield-county.com
TYPE OF CONSTRUCTION
® New Installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
❑ Alteration
❑ Repair
ID Dwelling 0 Transient Use 0 Comm/Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: Pauli Hayes & Gus Fitzgerald
Mailing Address:928 Branch Road Scottsville, VA 24590
Contractor: G u s Fitzgerald
Phone: ( 434 )962-4551 ---
Mailing Address:928 Branch Road Scottsville. VA 24590
Phone: ( 434 )962-4551
Engineer: Hepworth-Pawlak Geotechnical, Inc. Phone: ( 970
Mailing Address: 5020 County Road 154. Glenwood Springs. CO 81601
PROJECT NAME AND LOCATION
Job Address: 480 Pinion Point. Garfield County, CO
945-7988
Los Amgos Panch Subdivisson No, :' Fi ing No.
Assessor's Parcel Number: 2393-053-05-003 Sub. Lot 13 Block
Building or Service Type: Residential #Bedrooms: 3. . Garbage Grinder Yes
Distance to Nearest Community Sewer System: 1 M
Was an effort made to connect to the Community Sewer System: Not Feasible
Type of OWTS
Ground Conditions
Final Disposal by
O Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy
O Composting Toilet
O Recycling, Potable Use D Recycling 0 Ph Privy 0 incineration Toilet
O Chemical Toilet 0 Other
Depth to 1 Ground water table Not Ava• ab e Percent Ground Slope I4
O Absorption trench, Bed or Pit D Underground Dispersal 0 Above Ground Dispersal
O Evapotranspiration 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type 0 well 0 Spring 0 Stream or Creek 0 Cistem
la Community Water System Name
Effluent Will Effluent be discharged directly Into waters of the State?
DYes 13No
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.
1 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.
Okegve-zito
Property Owner Print and Sign
12&11trier)
27- 7o.t.�
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I'2.3.0I)
Perk Fee:
E 1vr.
Total Fees:
12-3.00
Fees
1 vr)
Building permit,
3_
Septic Permit:
-1L(a
°1 Issue Dat
11 C
Balance Du6e:
BLDG DIV: Al,4•-' ` / 45
APPROVAL DATE
112 siati , zoc---