HomeMy WebLinkAboutApplication - VOIDEDAE� Garfield County
RECEI
�� �01�Community Development Department
108 81h Street, Suite 401
GARFIELD COUNTYGIenwood Springs, CO 81601
COMM DEVELOPMENT (970) 945-8212
www.garfield-county.com
TYPE OF CONSTRUCTION
0 New Installation ❑ Alteration ❑ Repair
WASTE TYPE
0 Dwelling _ ❑ Transient Use ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Tim & Jeanie Lucas Phone: (970 ) 928-9154
Mailing Address: PO BOX 481, GLENWOOD SPRINGS, CO 81602
Email Address: TLBLDR05@GMAIL.COM
Contractor: OWNER Phone: ( )
Mailing Address:
Email Address:
Engineer: ALL SERVICE SEPTIC Phone: (970 ) 945-9)T3
Mailing Address: 33 FOUR WHEEL DRIVE ROAD, CARBONDALE, CO 81623
1 Email Address: CARLA.OSTBERG@GMAIL.COM
PROJECT NAME AND LOCATION
Job Address: TBD SADDLE RD.
Assessors Parcel Number: 218519400137 Sub. MTN. SPRINGS RANCH Lot 15 Block
Building or Service Type: CARETAKERS UNIT #Bedrooms: 2 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System: NOT AVAILABLE
Was an effort made to connect to the Community Sewer System: Nor AVAILABLE
Type of OWTS
O Septic Tank 1 ❑ Aeration Plant
1 ❑ Vault ❑ Vault Privy
Composting Toilet
❑ Recycling, Potable Use ❑ Recycling 1 ❑ Pit Privy ❑ Incineration Toilet
❑ Chemical Toilet ❑ Other
Ground Conditions
Depth to let Ground water table Percent Ground Slope
Final Disposal by
Water Source & Type
I.
O Absorption trench, Bed or Pit
❑Underground Dispersal
❑ Above Ground Dispersal
❑ Evapotranspiration
❑ Wastewater Pond '- ❑ Sand Filter
❑ Other
O Well ❑ Spring ❑ Stream or Creek ❑ Cistern
❑ Community Water System Name
Will Effluent be discharged directly into waters of the State? 0 Yes RI No
Effluent
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 requ
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:
C,C,
Perk Fee:
ON&•
Total Fees:
I�3 , aC)
Fees Paid:
l 2-3.06)
Building Permit
Septic Permit:
Issue Date:
Balance Due:
BUILDING/ PLANNING DIVISION:
Signed Approval Date
. 2 001/ C C.?117, TJ (c)