HomeMy WebLinkAboutApplicationLC__ Garfield County
'ACEI y Development Department
Stn Street, Suite 401
APR 1 'i 201 ss len ood Springs, CO 81601
(970) 945-8212
HY•• &..X)... W arfield-count .com
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
❑ , Dwelling 1 ❑ Transient Use
r:Other Describe 0/714 C
INVOLVED PARTIES
Property Owner: -4
Mailing Address:
Email Address:
Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
cl
C Alteration ❑ Repair
r
❑ Comm./Industrial ❑ Non -Domestic
Phone:
3-�'
Phone:
Phone:
0
PROJECT NAME AND LO TION _
Job Address: C1 L/C Hj' G C
Assessor's Parcel Number: �a ] 2 806W10%. �L Lot � Block
Building or Service Type: r• #Bedrooms: 7`y1;� Garbage Disposal(Y 2__
Distance to Nearest Community Sewer System: /L/0/1 -_P__
Was an effort made to connect to the Community Sewer System: _ r
Type of OWTS Septic Tank ❑ Aeration Plant ❑ Vault ❑ Vault Privy ❑ Composting Toilet
❑ Recycling, Potable Use ❑ Recycling ❑ Pit Privy ❑ Incineration Toilet
❑ Chemical Toilet f ❑ Other
Ground Conditions
Final Disposal by
Water Source & Type
Effluent
Depth to 11t Ground water table
Percent Ground Slope
b --Absorption trench, Bed or Pit ❑ Underground Dispersal ❑ Above Ground Dispersal
❑ Evapotranspiration ❑ Wastewater Pond ❑ Sand Filter
❑ Other
VWell ❑ Spring ❑ Stream or Creek ❑ Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? ❑ Yes O'No
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 irl�or anon which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
C..
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: DO Perk Fee: Total Fees: Feg� aid: LV
Building Permit Septic Permit: Issue Date: Bance Due-
BUILDING/ PLANNING DIVISION: /. - •! f f
Signed Approval ate