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Garfield County
Community Development Department
108 8th Street, Suite 401
R�IW) -a0p telenwood Springs, CO 81601
Gp' iyy(y DE (970) 945-8212
CDM�u www.garfield-countv•com
TYPE OF CONSTRUCTION
iI New Installation
WASTE TYPE
❑ Dwelling 1 0 Transient Use [ %1. Comm./industrial 1 0 Non -Domestic
0 Other Describe c E e.ANCt 1�
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
0 Alteration
0 Repair
INVOLVED PARTIES i,� ,ram
Property Owner: Cam' (c, .a.s ill 1 v At n c�k S Phone: (`f 7 3 ) - WOO
Mailing Address: L2S1 a,ticr 12 1. t 6mvld ,lctnchZ1) (C) �"I. u
Email Address: I'sbv1--1-, k,<..u'`5 a t„,acAC®F c0rrl
Contractor: l`rNt1'e (thvi tL i Lt.S Phone: 670 ) 2_-- 41'
Mailing Address: '2 2 1 3 RI 3C* l2•-.+st , (17, rAv ,Su rIc 41 641 , (c:.) lJ cb.�
Email Address: i uloQr--F- 1 .'- s 02‘..k.+rLA eotCc, rC cl
Phone:()
Engineer:
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: 7 `5t2- F t� �w17 4 -- i iF/ . f ei cp
Assessor's Parcel Number:21777I3( S"/ Sub. Lot Block
Building or Service Type: (vwsAfs-e`TL1.t` L
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
#Bedrooms:
Garbage Disposal(Y/N)
Type of OWTS
Ground Conditions
❑ Septic Tank ❑ Aeration Plant xi Vault 0 Vault Privy ❑ Composting Toilet
O Recycling, Potable Use 0 Recyd ng 0 Pit Privy 0 Incineration Toilet
O Chemical Toilet ❑ Other
Depth to is' Ground water table
Percent Ground Slope
Final Disposal by
Water Source & Type
Effluent
❑ Absorption trench, Bed or Pit
❑ Evapotranspiration
131 Other
pl Well 0 Spring
❑ Community Water System Name
0 Underground Dispersal
0 Wastewater Pond ❑ Sand Filter
0 Above Ground Dispersal
0 Stream or Creek ❑ Cistern
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 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.
T2oLcr4 LCZAR-S
Property Owner Print and Sign
i1/t. 119
Date
OFFICIAL USE ONLY
Special Conditions: pease. Ga ii (9;a) �{ KS- 66Ol '< 9I O a.t leafy 'i g kovrf n
,1044ce to A4ve 'Ca,' k. Ivt, iLwtiidvt. a6Se/ Ved_
Permit Fee:
IZ3• vo
Perk Fee:
LNG.
Total Fees:
124. od
Fees Paid:
I; 3. o0
Building Permit
131.0 ifel kg
Septic Permit:
%Pre. W66
Issue Date:
' i y z 0 O
Balance Due:
Ggr1XEr- �y,.ry P061.VISIO
K=ilfk•
ie. �' • i • _ Oe/ig7zoo
Signed Approval Date
PD.4 I23•0o/CPS, 11124 1