HomeMy WebLinkAboutApplicationRECE1V Community Development Department
µAY 0 ? V. 108 8th Street, Suite 401
Q.Iriwood Springs, CO 81601
GARFIELD GflU 1 ' (970) 945-8212
COMMUNITY DEvEt_0�{I'www.garfield-countv.com
Garfield County
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New Installation J 0 Alteration
WASTE TYPE
0 Repair
Dwelling
0 Transient Use
0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: lavk avd KruS•4-srt m_cAv
Mailing Address: 3(.10
Phone: (ot l o ) ''l fs-1.22 10 I
C c Cs l iv 5'2 -
Email
2
Email Address: d 7Q keNc o,i t ,Gvvv�
Contractor:
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
Phone: ( )
PROJECT NAME AND LOCATION
Job Address: -c3D c -4-a iz-d 23—I -r-oc `t sl 14, Go 551 (• es -2.
Assessor's Parcel Number: 7.\2'13(02 ocoittub. p�,-,k�e,• o -c.- e( Lot T �j `` Block
Building or Service Type: Vt•e lclevo-, #Bedrooms: Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System: Iv ( A
Was an effort made to connect to the Community Sewer System: iu o
Type of OWTS
I$( Septic Tank 0 Aeration Plant 0 Vault
0 Recycling, Potable Use 0 Recycling J 0 Pit Privy
0 Vault Privy n Composting Toilet
0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Depth to 1st Ground water table
Percent Ground Slope
Final Disposal by
O Absorption trench, Bed or Pit
Underground Dispersal
❑ Evapotranspiration
❑ Other
Water Source & Type
O Well
0 Above Ground Dispersal
0 Wastewater Pond 0 Sand Filter
0 Spring
0 Stream or Creek
Biq 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 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.
Kv >n 11 tea,
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Frofi.olt fortvzi9 OWT' 1 i 4,Ap►.f vip,v1 v- to c.0.
Permit Fee:
/23.00
Perk Fee:
�Iis' ,
Total Fees:
27-3.00
Fees Paid:
23-3. op
Building Permit
SLS -5L3
Septic Permit:
serer q-
Issue Date:
a<<t('
Balance Due:
BUILDING/ PLANNING DIVISION:
-Pa419-(, -irii-2.0�
Signed Approval Date
PD.-21-3_bo V1 461) //I