HomeMy WebLinkAboutApplicationGmfield Çounty ON.SITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
1Og 8th Street, Suite 401
RECEIVED Gtenwood Springs, co 81601
(970194s-82t2
SEP TZ 2018 www.sarfleld{ps¡ly.csm
GARFIELD
COMMU
tr Alteration tr RepairEI New lnstallation
tr Comm./lndustrial tr Non-Domestictr Dwelli El Trans¡ent Use
E Other Describe
Property Owner:
Mailing Address:
Phone
Email Address:ekaiter@comcast.net
1710 13th St Boulder CO 80302
Phone:Contractor:
Mailing Address:
Email Address:
33 Four Wheel Drive Rd Carbondale CO 81623Mailing Address:
Phone: (v/v )
\J\rV\r¿ltVEngineer:
Emai I Address: carla.ostberg @ gmail.com
Âll Ðervlue ùepUU vaf la L,rlttuuf I
Buitdingorservicerro", Residential plusADU #Bedrooms: 5 plus 2 GarbageDisposal(Y/N¡V
Was an effort made to connect to the Community Sewer System:
Assessor,s parcet Numbe r 2391-181-00-01Sub.
? N?A not availableDistance to Nearest Commun¡ty Sewer System
Lot BIock
Engineer looked into this
Job Address:I +ó+ tJt1 tUU Uaf Uoil(]are
PROJECÍ ¡rÀMå4{q
El Aeration Plant E Vault E vault Privy Composting ToiletnEl SepticTank
E Recycling E tit Rrivy E lnc¡nerat¡on ToiletE Recycling, Potable Use
El other
Type of OWTS
E chem¡cal Toilet
Percent Ground SlopeGround Conditions Depth to lst
trench, Bed or Pit El Underground Dispersal E Above Ground Dispersal
E Evapotranspiration Cl Wastewater Pond E Sand Filter
Final Disposalby
þ.).
E Other
E Well E Spring E SÍeam orCreek E Cistern
El Community Water System Name
Water Source & Type
Will EffluentbedischargeddirectlyintowatersoftheState? E Yes E noEffluent
Applicant acknowledges that the completeness of the application is conditiona! Vpgn such further
niãnOátorv and addii'lonal test and reþorts as may be required by the local health de.partment to be
mã¿e ànAÎurnished bv the applicant br by the local health department for purposed of the evaluation
of the appl¡cation; and'the isòüance of thé permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance with rules ánd regulations made, information and.reports submitted
herewith'and required tö be submitted by the,apþlicant are or will be rep.res.ented to be true and
correct to the beit of mv knowledge and belief and are designed to be relied on by the local
department of health in'evaluatin[ the same for purposes of issuing the permit applied for herein. I
further understand that any falsifiıation or misreþresentation 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 Certificat¡on above as well as
have provided the required is correct and accurate to the of knowledge.
V t'ìO a +{"
Property Owner Print and Sign
Special Conditions:
'ä''¿ä*Fees Paid:
ÇR3,aoPerk Feei
ÉL\G
Permit Fee:
4 na,ôo
Balance Due:,4d oolss¡¡gÎlãlè¡.4lrA/l,a'Building Permitì\lA SeDt¡c Perm¡t:
sEFt-.'5qı;$
BUILDING/ PLANNING DIVISION:
f
DateSigned
1-