HomeMy WebLinkAboutApplicationGarfield County
iuL 0 3 ,C imunity Development Department
i08 8tli Street, Suite 401
1 pwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
GARFIELD CO LI
COMMUNITY DEVELOP ll
TYPE OF CONSTRUCTION
$[ New Installation
WASTE TYPE_ _
a, Dwelling 1 ❑ Transient Use
0 Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
1 0 Comm./Industrial
1 _ ❑ _Repair
f❑ Non -Domestic
INVOLVED PARTIES
Property Owner: ,moi?1,e,x" ,
54,14.5 Phone: ( 17(-) )C2/13 47/7-4-,
Mailing Address: 20e:.‘" a -,z -lo L G.4446 Ca a;,/ b t.7
Email Address: align r4hao
Contractor: ./t..-
Phone:(
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address:: 7-
Assessor's Parcel Number: It,b7,40 I2 -I Sub.
Lot Block
Building or Service Type: S #Bedrooms: Z Garbage Disposal(Y/N)_ _
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS
Ground Conditions
Final Disposal by
AJD
❑ Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy ❑ Composting Toilet
❑ Recycling, Potable Use 0 Recycling 0 Pit Privy I 0 Incineration Toilet
O Chemical Toilet ❑ Other
Depth to 1st Ground water table
O Absorption trench, Bed or Pit
Percent Ground Slope
0 Underground Dispersal 0 Above Ground Dispersal
0—Evapotranspiration I 0 Wastewater Pond 0 Sand Filter
❑ Other
Water Source & Type
1 Effluent
O Well 0 Spring f 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 informaa is correct and accurate to the best of my knowledge.
or�I
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123. oo
Perk Fee:
dr). 00
Total Fees:
21'3.00
Fees Paid:
/23. 00
Building Permit
131.1w-58'33
Septic Permit:
SEPT- 5S3 /
Issue Date:Balance
10-027 le,
Due:
is u. uO
BUILDING/ PLANNING DIVISION:
(ko", 4/3/V0fof
Signed Approval Date
Ptt ell • o of C C) 112,119