Loading...
HomeMy WebLinkAboutApplicationGarfield County 1 t#3\I Wanmunity Development Department SOON 1N00,8 gm Street, Suite 401 GARE�EL WEVELO'�Waod Springs, CO 81601 �MM���yl (970) 945-8212 W Wy1Lga rf field-county.com TYPOF CONSTRUCTION ErNew Installation WASTE TYPE ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION 0 Alteration 0 Repair E Dwelling 0 Transient Use 0 Comm./Industrial 0 Other Describe, iX �t�� i f ck t' toi.pt•r ht>p 1`J' Vz bc, rk tG�'''l 0 Non -Domestic INVOLVED PARTIES Property Owner: G HaTtili US 1"n rj Phone: " ` 91 MailingAddress: Pb bt 4 C-Aft9ti c 4l C 0 ciiL 3 i I Email Address: ± i (9'1& 15 & x • G [ri .� J - } Contractor: [. of c Phone: �( 10 I c 11'1 4 ,) f Mailing Address: 0 PX)X / 14-- �• et i b tf1 d d C / D gid.)3 Email Address: ' (Cf' 4 J6 X • / a4-1 Engineer: Phone: ( ) Mailing Address: Email Address: PROJECTNAME AND LOCATION Job Address: t 5 7 21'�-i- } 1- r' L L 4.--0,01---La 4-1 ,10 04Q3 ,roc-, Pito Assessor's Parcel Number Building or Service Type: Distance to Nearest Community Was an effort made to connect 1 i9) 2- 0 c 1 Sub. MIA Loit/S.14T Block rt' IA c• -SL �W-Spjbs�i7 #Bedrooms: Ga ba eDisposal Y N (, Jli (� ) t,�' Sewer System: V/ A (1) r jj 4 .5 M,)'(-5. to the Community Sewer System: Arf 0 Type of OWTS Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy 0 Composting Toilet I 0 Recycling, Potable Use . 0 Recycling 0 Pit Privy ' 0 Incineration Toilet ❑ Chemical Toilet - 0 Other Ground Conditions Depth to 1rt Ground water table 1 Percent Ground Slope Final Disposal by BAbsorption trench, Bed or Pit ' 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration + 0 Wastewater Pond 0 Sand Filter ❑ Other Water Source & Type © Well 0 Spring J❑ Stream or Creek I 0 Cistern ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters ofthe State? ❑ Yes {�v }} J 1.S tI v► -IA' i4'r� Wt. i r 1�acti n UV) I l\ i`Q �t'VV ' L _ i �ihs1rbt1tiA �.1{Itt 1S rtes1"ret Irlw�l 11CLJ t ''4 � � V)(.11AA-004" i�777JJJ L„L f )L-,/ 1) �J�`l be tI 2CA i'. iv ; % 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 uunrihrctand 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. TiO1 C\'1S.1 (P1/1 Property Owne Srint and Sign 11/7-Ciart Date OFFICIAL USE ONLY Special Conditons: P,4ot> TIC --C) c �} �y frY� 1 0 CL* -44+7 AA...? 4 1,4.Vjt.,� / vV T r i'✓if/4 / ')1 Permit Fee: 1? -3 _ - Perk Fee: Total Fees: 29-3 - Fees Paid: 1-3 )S) - Bufldi�� it �� FII 5e�tic Permit: � 155 - ra ;• Balance Due: BUILDING/ PLANNING DIVISION: fir. {�� �~ /2--27t20-17 Signed Appr. gal Date Iv. 2 -3.00) 0-2_1ilz 1033iIt 7-0 -`