HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Depa rtment
^ nn . { ,rñr, 108 8th Street, Suite ¡101
Al't{ I I IUI' Glenwoodsprings,cost6ol
19701945-8212
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TYPE OF CONSTRUCNON
Xf New lnstallation fl Alteration n Repair
I,ì'ASTETYPE
F Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
t other Descríbe
II¡\'OLVED PARTIES
Property Owner:
Mailing Address:
EmailAddress:
¿
j(-¡rn
Phone:lîtsil 184- k>oX
Phone:f q?Õ | qsq-3oo8Contrector:
Mailing Address:
EmailAddress:
Engineer: Phone:
Mailing Address:
EmailAddress:
tì
PROJECT NAME ANT' LOCATION
Assesso /s Pa rcel Nu mber: 23ná:lö3: pô --eLtsu b. r/e-{ qI .p¿ Mi r^r çôb .
BuitdingorServiceType: Ne¡J C¿:nttt¡¿*r'on #Bedrooms:
Was an effort made to connect to the Community Sewer System:
3
Neerest Community Sewer System:Nl1Êr
Lot l- Block N/A
Job Address:
ñ /'fç-
Garbage Disposaljl o¡stance t,
tr CompostingToiletE Aeratlon Plant E V¡ult E vault klvyX,SepticTank
E Recycling EI Plt Pr¡w E lnclneratlon ToilctE Recycllng, Potable Use
E Chemlcâl Toilet El other
Type of OWTS
Depth to l"t Ground watertable-N|dla Peroent Ground SlopeGround Conditions
EI Undergrcund Dispercal El Above Ground DispersalI nbsorptlon trench, Bed or Pit
E Wastewater Pond E Sand FllterE¡ Evapotransp¡ratlon
t other
Final Disposal by
E stream orCreek E €isternp wett E SpringWater Source & Type
E Community Water System Name
Effluent Will Eff,uent be discharged d¡r€ctly into waters of the State? E Yes X t¡o
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
"iänA"io.V
ãnd add¡t-ional test and reports as rì.lay be required by the local health department to be
¡1ã¿ä àn¿î"rnished by the applicant br by the loèal healih department for pu.rposed.of the evaluation
of iñã ãóptiàat¡on; and the isiúance of thé permit is. subject to such terms and conditions as deemed
necersary to ínsuie compliance with rules and regulations made, information and reports submitted
trãiã*ittt'and required tö be submitted by the apþlicant are or will be represented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the local
áãpa.tment of health in'evaluatin[the same for purposes oÍ íssuing the,permit applied for herein. I
frrtñ"i ,nAerstand that any falsifíıation or misreþresentation may result in the denia.l of the
appiiCation or revocation of any permit granted based upon said applícation and legal actíon for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Not¡ce and Cert¡f¡cation above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
perty Date
LI,LI. L7
/d+roo l.ð Ð3 oo
OFFICIAL USE ONIY
Special Cond¡t¡ons:
Fees Paid:oo'"#';2,*ôoPermit Fee:qnA *Ë]i)â
*w"ä:@lssue Date:
Õ.ar . 1?SrÇ>t-41r(ß
Septic Permit:Building Permit
ß f1tr -\t ott4
zlpfuiBUTTD|NG/ PLANNING DIVISION
DateSigned