HomeMy WebLinkAboutApplication0 Stream or Creek
yir Community Water System Name
Will Effluent be discharged directly into waters of the State? 1:1 Yes ] No
Garfield County
000NI. Community Development Department
108 8th Street, Suite 401
�g •'‘ �'" 1`iGienwood Springs, CO 81601
AEL� c,0‘3"49,11 3p(970) 945-8212
pM ����Z� rE= www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
0 New Installation
WASTE TYPE
0 Alteration
Repair
Dwelling I 0 Transient Use 1 0 Comm./Industrial 1 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: .tir.a wvi rre r Phone: (6:. ) 3 L� '^ 5 7
Mailing Address: e�a, 'Q�%t -- 1 C •rib cAorvAss ! Co C114.0
Email Address: el`rb� ti{cJ-+ ' t.r�+r•l
Contractor: P►vc. GVte. eLVet-t Phone: (
Mailing Address:
Email Address:
Engineer:
Phone:
)
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION _
Job Address: -" - iGnw+c - - • C Cc. 1:
Assessors Parcel Number:((�� -- '.1€5'pat -S`Sub. �:Pi e[�-. W�--. 5 its. Lot a Block (et
i
Building or Service Type: 1 `i 1
� 1‹.-^-6--k #Bedrooms: c Garbage Disposai'(Y/.IV)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: MI'
Septic Tank ❑Aeration Plant
1 ID Vault 0 Vault Privy
Type of OWTS
Ground Conditions
Final Disposal by
0 Recycling, Potable Use
O Chemical Toilet
O Recycling
0 Pit Privy
❑ Composting Toilet
0 Incineration Toilet
0 Other
Depth to 1" Ground water table
Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal
O Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
O Other
O Well 0 Spring
Water Source & Type
Effluent
0 Cistern
N+? NAS ►.,ate rz T�kSSr.�(1T ism
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 hich is correct and accurate to the best of my knowledge.
L�y
Property Owner Print and Sign
e.
Date
OFFICIAL USE ONLY
Special Conditions:
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4 t:c - - ' B.gpm c _
Permit Fee:
1-5
Perk Fee:
Total Fees: Th5
Fees Paid: J
Building Permit
Septic Permit:
Issue Date:
Balance Due:
BUILDING/ PLANNING DIVISION:
ar 41010 '9- it' JJ
igne• Approva Date
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