HomeMy WebLinkAboutApplicationRace
1Community Development Department
F����
sA+RvIELD V 108 ' Street, Suite 401
enwood Springs, CO 81601
raMVAUNI OKel(970) 945-8212
www.garfieid-county.com
Garfield County J
TYPE OF CONSTRUCTION
❑ New Installation
WASTE TYPE
Dwelling 0 Transient Use TO Comm./Industrial 0 Non -Domestic
❑ Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
T ❑ Alteration -
Repair
iravvurcu rpm . 1G.,
Property Owner: 4 P(t) ` i�jiR� 1 i `t - Phone: t .)•L 1 4 0 (' 11
y,
[�lam'
Mailing Address: 1- • i"' DD LOC b Z1 V
+ L
Email Address:
1 kr U tr
Contractor: 0 •r
Phone:
Mailing Address: I 1 OA
1 VDU
A
Email Address:
Engineer: SW—
Phone: 1. )
Mailing Address:
Email Address:PROJECT
Job Addre Address: 41- ID
mead. Dk _ Dr. - -.01-.e_
OIC' •
jQ
#V1OSu
� DvvbAssessor's
Parcel N�7``uymber:,
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
I ( Sub• �� i� �ot. �' I Block
DIA)414 W& #Bedrooms: ? .jlc—Garbage Disposal(Y/N)
Sewer
to the
System:
Community Sewer
System:
Type of OWTS
KSeptic Tank 0 Aeration Plant 0 Vault
I 0 Vault Privy Composting Toilet
❑ Recycling, Potable Use
0 Recycling 0 Pit Privy
I 0 Incineration Toilet
❑ Chemical Toilet
0 Other
Ground Conditions
Depth to 15t Ground water table
Percent Ground
Slope
Final Disposal byAbsorption
trench, Bed or Pit i 0 Underground Dispersal
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type
0 Well
0 Spring 0 Stream or Creek
0 Cistern
Community Water System
Name
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon each 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
h
wiedge that I have read and understand the Notice and Certification above as well as
the required information which is correct and accurate to the best of y knowledge.
r7
Property Owner Print and Sign
eQ
Date
OFFICIAL USE ONLY
Special Conditions:
Cr /Fi-t-
U
Permitee: —
Perk Fee:
Total Fees:
Fees Paid:
Building Permit
``--
Septic Permitt:Is
Se-Cr-Jk3;'
- + -:
Balance Due:
BUILDING/ PLANNING DIVISION:
`
S -2p
-2'/
Signed Ap . royal
Date