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HomeMy WebLinkAboutApplicationGarfield County RECEDED Community Development Department 108 8th Street, Suite 401 Ni 1 3 2.01uN.�,�lenwood springs, co 81601 A���EL0 GOgF�SH� (970) 945-8212 GgMM��ti�Y []i www.garfield-county.com TYPE OF CONSTRUCTION _ ❑ New Installation WASTE TYPE - MDwelling 1 0 Transient Use ❑ Other Describe ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TO Alteration _ Repair Comm./Industrial J❑ Non -Domestic INVOLVED PARTIES t 4 Property Owner: \A1 kk_LCY y x.- e `� MailinQAddress: S O �S\ti b ? Phone: l_ f__ -I-A-r n"►-. 4..e ' Email Address: \JPLL . c�t Contractor: n I "im d, Co Phone: lid i `1a-1in Mailing Address: Email Address: Engineer: Phone: ( Mailing Address: Email Address: PROJECT NAME AND LOCATION _.. Job Address: --6q5 StAk, �tvt tY• Assessor's Parcel Number: Sub. til�� Lot 3 Block 2-- e)/���,,/�� #Be�oomms: 3 Garbage Dis osal(Y/N) Building Service Type: � S V`�/Y ll.Ci g P Building or Distance to Nearest Community Sewer System: Vl 1 Was an effort made to connect to the Community Sewer System: it 1°1' Type of OWTS — Septic Tank 1 ❑ Aeration Plant 0 Vault I 0 Vault Privy L Composting Toilet ❑ Recycling, Potable Use 0 Recycling 13 Pit Privy f0 Incineration Toilet ❑ Chemical Toilet © Other Depth to 1g' Ground water table Percent Ground Slope Ground Conditions Final Disposal by k Absorption trench, Bed or Pit i 0 Underground Dispersal 1 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter ❑ Other Water Source & Type llt Well 0 Spring 0 Stream or Creek J 0 Cistern ❑ Community Water System Name Effluent Will Effluent be discharged directly into waters of the State? 0 Yes I No CERTIFICATION Applicant acknowledges that the completeness of the application is conditional upnn sur_h 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 an -57- 1.-5 z c Date OFFICIAL USE ONLY Special Conditions: Permit Fee: Perk Fee:' Total Fees: 3t Fees Paid: 7-S- BuildingLPerEnit sk R, Sep SePT— ue Iss131 f� Balance Due: BUILDING/ PLANNING DIVISION: 8-2,c:)/(t Sig ai Date IPP> 4' W,. e --C-, r//3/ /1