HomeMy WebLinkAboutApplicationisGarfield County
Community Development Department
,„,0 108 8th Street, Suite 401
Glenwood Springs, CO 81601
►N )QV/ (970) 945-8212
�P►Q pl► .garfield-county.com
�pHPE OF CONSTRUCTION
0 New Installation
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
WASTE TYPE
0 Dwelling
r❑ Other Describe
0 Repair
0 Transient Use
❑ Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
(
Property. Owner: Nona Niland Phone:
Mailing Address: 2331 CR 100, Carbondale, CO 81623
Email Address: nonaniland@me.com
Contractor: Phone:
(�
Mailing Address:.
Email Address:
Engineer: ALL SERVICE septic, LLC (Richard Petz / Carla Ostberg)
Phone: ((970)309.5159
Mailing Address: 33 Four Wheel Drive Road, Carbondale, CO 81623
Email Address: carla.ostberg@gmail.com
PROJECT NAME AND LOCATION
_
Job Address: 2331 CR 100, Carbondale, CO 81623
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
2393-364-00-271 Sub. Lot Block
residence #Bedrooms:
3
Garbage
Disposal(Y/N)
Sewer System:
to the Community
2 miles
Sewer System:
no / not applicable
Type of OWTS
El Septic Tank
0 Aeration Plant
0 Vault 1 ❑ Vault Privy
❑ 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
est 1'
Percent Ground Slope
flat
Final Disposal by
0 Absorption trench, Bed or Pit 0 Underground DispersalI 0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond
El Sand Filter
❑ Other mounded sand filter
Water Source & Type
El Well
0 Spring 0 Stream or Creek r❑ Cistern
❑ Community Water System
Will Effluent be discharged
Name
directly into waters of the State?
Effluent
0 Yes El No
MAR -23-2018 11:01AM From:Residence Desk 5125423637 To:919709630289 Pa9e:4/5
Applicant acknowledges that the completeness of the application is titional al upon
department to be
mandatary and additional test and reports as may be required by the local
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the isskjance 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 slubmitted 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.
APAof. Al/'.4—,ib �..
Property Owner Print anis Sign, - 0/44/ '6641re/Q- Le Date
QFFicmt,: 45E..0NLY
Special Conditions:
Permit Fee:
123 -
Building Permit
131V -C-11-1-4
•
Pork Fee:E a total Fees:l
•
Septic 'ermit• Issue Date:
s►r- 51
BUILDING/ PLANNING DIVISION:
PD
Fees Paid:
123'
Signed Approval
Iv).00, 4-Id0,12-3hg
Balance Due:
41/0as
Date