HomeMy WebLinkAboutApplicationGarfield County
ReGEN Community Development Department
6(L�1`.) 108 8th Street, Suite 401
I� ettfa rood Springs, CO 81601
GA11En �0Ptat"(970) 945-8212
CO M►]ta‘T`f www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
XNew Installation
WASTE TYPE
❑ Alteration
Ts Dwelling
0 Transient Use
0 Repair
0 Comm./Industrial
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 1M1-1 -� Phone: )
Mailing Address: (ijl jj 23 r d ei co, z i SO5
Email Address: - C 1cLam'\. U' CJ �.l tin h(mAt C(rne )
Contractor:
Mailing Address:
Email Address:
Phone:(
Engineer: LI LTJ CT r y�irn T �7 — < CJ I _ s+-
Phone:
Vb, Box fl S VN‘A-t, U SgoY
Mailing Address: _
Email Address: votrv'.6.00, 2 E G-0)QCD C,lty£ -"4(T^ CD/w\
PROJECT NAME AND LOCATION
Job Address:
Assessor's Parcel Number: 24L11 ZC ? �,.,x J� fLn
Building or Service Type: I Vki.I3,7-01Cyk f J4 OF edrooms: 4
Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Lot 2_ Block
Type of OWTS
rSeptic Tank
0 Aeration Plant
0 Vault
0 Vault Privy
Composting Toilet
O Recycling, Potable Use
O Recycling
0 Pit Privy
0 Incineration Toilet
O Chemical Toilet
0 Other
Ground Conditions
Final Disposal by
Depth to 10 Ground water table
Absorption trench, Bed or Pit
O Evapotranspiration
Percent Ground Slope
0 Underground Dispersal 0 Above Ground Dispersal
O Wastewater Pond r 0 Sand Filter
O Other
Water Source & Type
Effluent
Well 0 Spring 0 Stream or Creek
0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State?
❑ 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 informatio which is correct and accurate to the best of my knowledge.
C
Property Owner Print and Sign
6411!c( 6/12--/(9
Date
OFFICIAL USE ONLY
Special Conditions: fo L. copy of 944 ,,,[4,V,49.i. 41,-/1/1/1 Af JOIG0 al f• -e• fbv
lateAW r Wkoi et ie lAtAV 9 aoyf reel( 1v NIAI IHgrscr tf 44/ . O.
Permit Fee:113'00
�. �
Perk Fee: c�� •
Total Fees: I `� DO
Fees Paid: /rD
, J o
Building Permit
etMF51 11
Septic Permit:
SCAT 000
Issue Date:
1.1 a
Li
Balance Due:
.
BUILDING/ PLANNING DIVISION:
3/(0
7/11/1 1.1
Signed Approval
) Date
PD.f, I14•oo)/-1ylMl¢, (0111