HomeMy WebLinkAboutApplicationGarfield County J
250 Community Development Department
0tl�% 108 8"' Street. Suite 401
NRLf1r-DcaE o,LDpMEH�lenwood Springs, CO 81601
790°11(970) 945-8212
www.garfield-county.corn
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
❑ New Installation T T ❑ Alteration
WASTE TYPE
JEI Dwelling 1 ❑ Transient Use_ l ❑
T g Repair
Comm./Industrial !❑ Non -Domestic
0 Other Describe
INVOLVED PARTIES _ _
Property Owner: tt- e I 141 W p SSo
Phone: (� ) '4 r -O aS 3
Mailing Address: V• ° • ya�;2 A 31235-` / • 1.--`"' S‘1�4e.,:a
Email Address: I ' I Im Y1'1 r�{'i- i < <'
Contractor: t (p r ►t' G• LLL— Phone: ('I' [ IrliMEChrit
Mailing Address:
Email Address:
Engineer:
q 5 3 L44 "t" 'Z'D • 2-14 ry E") (,r (L to .
C cye I(c( yloe4i t . £ -'
964-1141
Mailing Address: _
Email Address:
Phone:
PROJECT NAME AND LOCATION
Job Address: ;‘)5 W rhit C405 -11k
{
Assessor's Parcel Number:
Building or Service Type: •• LtA.9
Distance to Nearest Community Sewer System:
Sub. Lot
#Bedrooms:
4✓+( t
Was an effort made to connect to the Community Sewer System:
Block
Garbage Disposal(Y/N)___
Type of OWTS ( ISI Septic Tank 0 Aeration Plant
❑ Recycling, Potable Use 0 Recycling
❑ Chemical Toilet
❑ Vault 0 Vault Privy I Composting Toilet
0 Pit Privy I- 0 Incineration Toilet
❑ Other
2
Ground Conditions
Depth to ist Ground water table
Percent Ground Slope _t&.+
Final Disposal by
Absorption trench, Bed or Pit i 0 Underground Dispersal I 0 Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond 0 Sand Filter
O Other
Water Source & Type
I)15 Well
0 Spring
0 Stream or Creek 0 Cistern
O 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 upnn 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. 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.
Propert4 3 caner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Building Permit
Perk Fee:
Septic Permit:
5e4x- 5(12+-1
BUILDING/
(12+-
BUILDING/ PLANNING DIVISION:
Total Fees:
Issue Date:
Fees Paid:
Balance Due:
Signe . Approval
00) 1* co 3, 9--
7-27-2 c/9
Date
We6501.5 tQ
'55111- ikwY b
1J e tid C
1r
l4
Air
•
tit- [�'� MELD
I
fat