HomeMy WebLinkAboutApplicationRECEN
00 3 20 Community Development Department
108 8"' Street, Suite 401
GCOMVEY n CO MEN lenwood Springs, CO 81601
COMM (970) 945-8212
www.garfield-county.com
Garfield County
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation
WASTE TYPE
1 0 Alteration
Dwelling 0 Transient Use _ 0 Comm./Industrial
0 Repair
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: ('Lf1k Collins Phone: (qlO)
Mailing Address: +D 15-5.— V3 Imo. LAC f• r�lll.PQj
Email Address: Co M r\$ ' i4 ? aO1 • LO+n
Contractor: �.7� S �.s�- � lcr w• (t r- Phone: ( 6.9t ) 1a-17 25 -
Mailing Address: Lt. C R 2t.J t
Email Address:)� ,���tl t • LO
r}n,r�, Q•
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION 131
Job Address: '71a 17 C C.�t (2 4) -
Assessor's Parcel Number: Z1Z3-142 a'- 17l5ub. Lot Block
Building or Service Type: (k5. iiBedrooms: Garbage Disposal(Y/N) `)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Septic Tank I 0 Aeration Plant 0 Vault 0 Vault Privy I n Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
❑ Chemical Toilet 0 Other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
Final Disposal by
Water Source & Type
Effluent
Absorption trench, Bed or Pit
❑ Evapotranspiration
❑ Other
Well 0 Spring
0 Underground Dispersal 0 Above Ground Dispersal
0 Wastewater Pond 0 Sand Filter
0 Stream or Creek
0 Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes
CERTIRCATSOMI
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.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
I23•b0
Perk Fee:
IP.op
Total Fees:
2-13.
00
Fees Paid:
21-3.o0
Building Permit
134E -6j4
Septic Permit:
61-S
Issue Date:
I1IW (
Balance Due:
BUILDING/ PLANNING DIVISION:
•�� r
% �� ,Q
•
Sign=. Ap.r• .
Date
3 uo, J 7,4-1,7_, 11D 13► l l(