HomeMy WebLinkAboutApplicationRECEIVED
APR 0 9 2018
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
Garfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfleld-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TY E OF CONSTRUCTION
New Installation ❑ Alteration
WASTE TYPE
Dwelling 0 Transient Use 0 Comm./Industrial L 0
❑ Other Describe
—7— 0 Repair
Non -Domestic
INVOLVED PARTIESi _
Property Owner: ) t1' P►N Phone: ( ) Q
Mailing Address: FOOD`. 2.1 DI = Z.E.0 IE.. CO 6 ( (030
Email Address: v`iAAr I'' ' � r CH
Contractor: Cae..W1- �iC.MAE LLC. Phone: co Mailing Address: f oCahYRr" 1 '��rL— 0444E. c2 J 6,0 gI 7 co
Email Address: Joss -0 a, 1 CJtC D
Engineer: Aq`.]rit7 e.. EPA .
Mailing Address: (c B 9 p C G _S3 BtSo IJ
Email Address: rifts ' wt Cha •11s7aw02--+4esT i`'k
Phone: -4- • 33J1
PROJECT NAME AND LOCATION
Job Address: 1'7% 14132. C.11 {L.D 2 a j
Assessor's Parcel Number2U.,S 2S1 C7002Q Sub. Lot __. Block
Building or Service Type: 10+L #Bedrooms: 3 Garbage Disposal(Y/N) ,
Distance to Nearest Community Sewer System: V�. F7EQ kM } C.40 16 rA l Lzb
Was an effort made to connect to the Community Sewer System:
Nfl
Type of OWTS 0 Septic Tank 0 Aeration Plant t 0 Vault I 0 Vault Privy
Ej Composting Toilet
O Recycling, Potable Use
O Chemical Toilet
0 Recycling 0 Pit Privy
0 Incineration Toilet
0 Other
Ground Conditions
Final Disposal by
Depth to 1" Ground water table
Percent Ground Slope
O Absorption trench, Bed or Pit 0 Underground Dispersal
I❑
O Evapotranspiration 7 0 Wastewater Pond ❑ Sand Filter
Above Ground Dispersal
O Other
Water Source & Type
Well I ❑ Spring 0 Stream or Creek
1 _.
Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
0 Yes yi No
RAN: 4
Q�
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. 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.
1 hereby acknowledge that I have read and understand the Notice and Certification above as well as
have rovided a required information w ch is correct and accurate to the best of my knowledge.
61, fl , rYtl rl 3 / 2 7 7 (�
Date
Property Owner Print and Sign
vv. 123. a' 123311, 4/3018
Special Conditions:
Permit Fee m
Perk Fee: Total Fees:
ENS.?,
Fees Paid: 2 C D
3•
12;
B aiding Permit
-5I3'S:sf-5i_-.AM
Septic Permit: _ Issue Date:
`i',.
Balance Due:
BUILDING/ PLANNING DIVISION
1110" PP -
-`ifs
__Ior21Z,i1-8
Sign d Appro al
Date
vv. 123. a' 123311, 4/3018