HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
0 New Installation
WASTE TYPE
0 Dwelling
0 Other Describe
0 Transient Use
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
1 ❑ Alteration
❑ Comm./Industrial
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Heath, Sabina Cotter
PO Box 549 Rine, co 61650
Mailing Address:
Email Address: healhcolter@gmail.com
Phone: (Me/ 270.orga
Contractor: Tally Ho Construction Inc
Mailing Address: 0145 County Rd 225 Rifle, CO 81650
Email Address: tallyhoconst@sopris.net
Phone: ({B7a]625 e
Engineer: Phone: (_)
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: TBD Gage Road Rifle,C0 81650
Assessor's Parcel Number: 217735300529
Building or Service Type: Residential
Sub.
Lot Block
#Bedrooms: 4 Garbage Disposal(Y/N) n
Distance to Nearest Community Sewer System: NA
Was an effort made to connect to the Community Sewer System:
Type of OWTS 0 Septic Tank L 0 Aeration Plant 0 Vault 0 Vault Privy n Composting Toilet
❑ Recycling, Potable Use 0 Recycling I 0 Pit Privy 1 0 Incineration Toilet
❑ Chemical Toilet r 0 Other
Ground Conditions
Depth to 1st Ground water table NA
Percent Ground Slope a%
Final Disposal by
D Absorption trench, Bed or Pit El Underground Dispersal L❑ Above Ground Dispersal
O Evapotranspiration f 0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type
IRR Well 0 Spring 0 Stream or Creek I 0 Cistern
O Community Water System Name
Effluent
Will Effluent be discharged directly into waters of the State?
❑ Yes 0 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 departmcnt 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.
I 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.
Property Owner Print and Sign
/its' dci?-
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Perk Fee: 63T
tall Fees: c.
Fees Paid:
Building Permit
grY--sD
Septic Permit:
�T�-`PT- 509.14
Issue Date:
1 11 i< , -
Bance D
•
12/0 //017Signed
BUILDING/ PLANNING DIVISION:
Approval Date