HomeMy WebLinkAboutApplication - ADU��r;'�G Community Development Department
0�"('j08 8th Street, Suite 401
0 G� gptnwood Springs, CO 81501
S\'�' 0 (970) 945-8212
C,11` NNW' www.garfield-county.com
Garfield County
TYPE OF CONSTRUCTION
!I New Installation
WASTE TYPE _
_El Dwelling 0 Transient Use
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
1
0 Comm./Industrial
0 Repair
1 0 Non -Domestic
INVOLVED PARTIES _
Property Owner: CMH Homes, Shawn Ruse
Phone: (303 ) 250-37
Mailing Address: Clayton Homes #1037, 671 23 Road, Grand Jct., CO 81505
Email Address: kateschwerin@gmail.com
Contractor: CMH Homes
Phone: (
Mailing Address:
Email Address:
Engineer: Vance King, CiVCO Engineering, Inc.
Mailing Address: PO Box 1758 Vernal. UT 84078
Email Address: vancekinq@civcoengineering.com
PROJECT NAME AND LOCATION
Job Address:
■.s 11 -
Phone: ( 435 ) 789-5448
u -..-
Assessor's Parcel Number: 2393-24 1-05-003Sub. West Rimiedge Sub Lot
3 Block
Building or Service Type: Residence/Home #Bedrooms: N
Distance to Nearest Community Sewer System: 10 miles
Was an effort made to connect to the Community Sewer System:
hID Septic Tank 4 0 Aeration Plant 113Vault 0 Vault Privy E Composting Toilet
❑ Recycling, Potable Use 0 Recycling I 0 Pit Privy I 0 Incineration Toilet
O Chemical Toilet 0 Other
Type of OWTS
3 Garbage Disposal(Y/N)
NO
Ground Conditions
Depth to lst Ground water table
Percent Ground Slope
Final Disposal by
Water Source & Type
Effluent
ID Absorption trench, Bed or Pit 1 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration 1 0 Wastewater Pond 1 0 Sand Filter
❑ Other
O Well ❑ Spring I 0 Stream or Creek
O Community Water System Name
0 Cistern
Will Effluent be discharged directly into waters of the State?
❑ Yes CI 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 information which is correct and accurate to the best of my knowledge.
erty Owner Print and Sign
9/20/18
Date
OFFICIAL USE ONLY
� .
Special Conditions:
Permit Fee:
I2.--
Perk Fee:
l�
Total Fees: _
2 I-3
Fees Paid: _
2�3
Building Permit
5
131,11; S4
Septic Permit:
Sq ' 5LASS
Issue Dae:
D
1 I
22
It
Balance Due:
BUILDING/ PLANNING DIVISION:
sii
Ib/I1 I �f1 rt
Signed Approval Date
/-1-3.o0) CC) 1 b I l $