HomeMy WebLinkAboutApplicationEC II) 1 V
DEC 0 8 2017
Garfield County
GARFIELD COUNT
Y
'MMUN TY OFVF.LUr:Vi,,'4.
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.corn
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Property Owner: Mike Whitman Phone: (970-230-°fi4
Mailing Address: 143 N. Meadow Dr Rifle, CO 81650
O New Installation
Contractor: owner / Same as above Phone: (
• Alteration
• Repair
WASTE TYPE
Mailing Address:
PROJECT NAME AND LOCATION
— Dwelling
• Transient Use
• Comm./Industrial
• Non -Domestic
Was an effort made to connect to the Community Sewer System: N/A
• Other Describe
O Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
INVOLVED PARTIES
Property Owner: Mike Whitman Phone: (970-230-°fi4
Mailing Address: 143 N. Meadow Dr Rifle, CO 81650
Contractor: owner / Same as above Phone: (
Mailing Address:
Engineer: NIA Phone: ( )
Mailing Address:
PROJECT NAME AND LOCATION
Job Address: 143 N. Meado) 4ilt, CO 81652 / Mailing address 143 N. Meadow Dr. Rifle, CO 81650
Assessor's Parcel Number: 2179-052-02-012 Sub, Lot Block
Building or Service Type: Single Family Dweling #Bedrooms: 2 Garbage Grinder ZA
Distance to Nearest Community Sewer System: N/A
Was an effort made to connect to the Community Sewer System: N/A
Type of OWTS
O Septic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 1°` Ground water table > 15'
Percent Ground Slope 5%
Final Disposal by
G Absorption trench, Bed or Pit 0 Underground Dispersal
1 0 Above Ground Dispersal
(Filter
❑ Evapotranspiration
1 0 Wastewater Pond I 0 Sand
❑ Other
0 Well
0 Spring
0 Stream or Creek
0 Cistern
Water Source & Type
GI Community Water System Name Sun Meadows Estates
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes ii No
CERTIFICATION
ApplicanL 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. 1
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 /77/7L vI}larnd---
12-7-/7
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee:
isz,
Total Fees:
Fees Paid:
Building Permit
gtE—Sb461
Septic Permit:
—PAP
Issue Date: 1
12-2i-11--
Balance Due:
BLDG DIV: 414 (2/2I110r7
APPROVAL DATE
1. K- J
2-