HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Comm:! ..,r " i: / :
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JUil I 4 ?017
lr,
unity Development Depertment
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 94s-8212
www.garfield-countv.com
TYPE OF CONSTRUCÍION
tr New lnstallation tr Alteration tr Repair
WASTE WPE
EI Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property OWnef : Nlchole Smith Phone:24
Malling AddrgSS: '137 Rouncltree Rd Rifle' co 81650
EmailAddress:nsmith27621 @gma¡l.com
Contfactof: Mountain Wsst Contracting LLC Phone:
Mä¡l¡ng AddreSS: 5440 cR 331 silt, cO 81052
Email AddfeSS: mountainwsslcontracting@aol.com
Engineer:Phone: (
Malling Address:
EmailAddress:
PROJECT NAME AND LOCANON
Job Address:4Í17 Houndtree Rd Rillé, CO 81650
ASSeSsO/S ParCel NUmbg¡i 2127-334@117 SU b. Antlers Orchard fot rrack 3s Block
Building or Seruice Type:Dwelllng #Bedrooms: s Garbage Disposal{Y/N}Y
Distance to Nearest Community Sewer System:NA
Was an effort made to connect to the Community Sewer System:NA
Type of OWTS E SepticTank E Aerat¡on Plant E Vault E Vault Privy I ComRostingToilet
E Recycling, Potable Use El Recycllng [1 lit ertuy E lncineration Toilet
El Chem¡calTo¡let E other
Ground Conditions Depth to ls Ground water table Percent Ground Slope
FinalÐisposal by E Absorpt¡on trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
El Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type E weil E Spring E Stream orCreek E cistern
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes E tr¡o
Applicant acknowledges that the completeness of the application is conditiona! 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 thât I have read and undêrstand the Notice and Certlfication above as well as
have provided the required fnformation which is coreçt and accurate to the best of my knowledge,
1
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