HomeMy WebLinkAboutApplicationRC
7 419imunity Development Department
ARFIL �
.408 8th Street, Suite 401
ppiwood Springs, CO 81601
temoolo
(970) 945-8212
www.Rarfield-county.com
Garfield County
TYPE OF CONSTRUCTION
El New Installation
WASTE TYPE
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
❑ Dwelling 0 Transient Use 0 Comm./Industrial
❑ Other Describe
❑ Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Garfield County
Mailing Address: 0075 CR 246, Rifle, CO 81650
Email Address: dfiscus@garfield-county.com
Contractor: Kuersten Construction, LLC.
Phone: ( 970 ) 625-2516
Mailing Address: 13 Powerline Rd, Rifle, CO 81650
Email Address: John@kuerstenconstruction.com
Engineer: Sanborn, Head and Associates, Inc.
Phone: ( 970 ) 618-9518
Mailing Address: 3350 Peoria St, Suite 150, Aurora, CO 80010
Email Address: mkozlowski@sanbornhead.com
PROJECT NAME AND LOCATION
Job Address: 0075 CR 246, Rifle, CO 81650
Phone: ( 303 ) 915-7058
Assessor's Parcel Number: 217520100187 Sub. N/a
Building or Service Type: LF scalehouse & admin bldgs #Bedrooms:
Distance to Nearest Community Sewer System: > 1 mile
Was an effort made to connect to the Community Sewer System: No
Type of OWTS 0 Septic Tank 0 Aeration Plant 0 Vault 0 Vault Privy Composting Toilet
O Recycling, Potable Use 0 Recycling 0 Pit Privy 0 Incineration Toilet
Lot N/a Block N/a
N/a Garbage Disposal(Y/N) No
Ground Conditions
Final Disposal by
O Chemical Toilet 0 Other
Depth to 1st Ground water table > zo ft beg
Percent Ground Slope -1%
O Absorption trench, Bed or Pit 0 Underground Dispersal
O Evapotranspiration 0 Wastewater Pond
0 Above Ground Dispersal
0 Sand Filter
0 Other Pumpout for disposal.
Water Source & Type 0 Well 0 Spring 0 Stream or Creek 0 Cistern
O Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes
Effluent
0 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.
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: h
1 a
Perk Fee: I ct
Total Fees: r\ 1 cc
r Fees Paid: 0 1 o
Building Permit
i3L�b_51
Septic Permit:Issue
SEPT- �� 5
Date: i
toI
Balance Due:
BUILDING/ PLANNING DIVISION:
'� - 3 20/7
Signed A .Prov • .• Date