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HomeMy WebLinkAboutApplicationIle Garfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970} 945-8212 www.earfield-county..com TYPE OF CONSTRUCTION 19 New Installation ❑ Alteration WASTE TYPE _ C5 Dwelling ❑ Transient Use j ❑ Comm./Industrial ❑ Other Describe ❑ Repair ❑ Non -Domestic INVOLVED PARTIES Property Owner: Dean Dombrowski Phone:( 970 ] 618-7033 Mailing Address: 415 Elk Circle Basalt, CO 81621 Contractor: Double D Property Management Phone: ( 970 ] 618-7033 Mailing Address: 415 Elk Circle Basalt CO 81621 Engineer: All Service Septic Phone: ( 970 ] 309-5259 Mailing Address: 33 Four Wheel Drive Road, Carbondale, CO _81623 PROJECT NAME AND LOCATION Job Address: Assessor's Parcel Number: 2393-074-00-019 Sub. Lot Block- Building lock_ Building or Service Type: Office #Bedrooms: 0 Garbage Grinder Distance to Nearest Community Sewer System: The distance is greater than 5 miles Was an effort made to connect to the Community Sewer System: no effort was made to tie into city sewer Type of OWTS Septic Tank 1 Cl Aeration Plant ❑ Vault ❑ Vault Privy ❑ Composting Toilet ❑ Recycling, Potable Use T❑ Recycling 1 ❑ Pit Privy ❑ incineration Toilet Chemical Toilet ❑ Other Ground Conditions Depth to 1" Ground water table greater than 8 I Percent Ground Slope 2yo Final Disposal by Ed Absorption trench, Bed or Pit ❑ underground Dispersal ❑ Above Ground Dispersal ❑ Evapotranspiration ❑ Wastewater Pond 1 ❑ Sand Filter ❑ Other Water Source &Type Well © Spring ❑ Stream or Creek 13Cistern ❑ Community Water System Name [E_ffluent Will Effluent be discharged directly into waters of the State? ❑ Yes C�' 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. Property Owner Print and Sign Date OFFICIAL USE ONLY Special Conditions: Permit Fee: Perk Fee: Total Fees: Fees Paid: CIO 0' Z/;29. °Q (`/0?3, Building Permit Septic2irmit, Issue Date: Balance Due: ad BLDG DIV: APPROVAL DATE rWd Cg. u5•t W °°