HomeMy WebLinkAboutApplicationGøffield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
APR 2 4 e0l?Community Development Department
t08 8th street, Suite 401
Glenwood Springs, CO 81601
(970194s-8212
www.ga rfield-cou ntv.com
WPE OF CONSTRUCTION
Ú ru"* tnstillation
WASTE WPE
I Dwelling r E Tr;nsient Use
E Other Descríbe
j E Rlteration tl Repair
! !_ comm,ltn dustrial i n Non-Domestic
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I ¡ruvolgo PART|ES
Property Owner:
Mailing Address:
Email Address:
Confractor:
Mailing Address
Email Address:
Engineer:
4\¿:
\,\F Phone:
Phone:¡TIøi 4t?-ozço
(þ t
\o C-
PROJECT NAME AND TOCATION
JobAddress: / o) - K'..o.s ç\ o.r/ A,\^C-
Assessor's Parcel Number, øt 7 Block
-Euilding or Service Type:
-
*sedroo; 9 earbage Disposal 6istanc.
Mailing Address:
Email Address:
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Nearest Community Sewer System:-2
Was an effort made to connect to the Community Sewer System:fVo
FinalDisposalby E Absorption trench, Bed or Pit E Underground Dispersal E Above Ground D¡spersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
O well E Spring C¡sternWater Source & Type xCommunity Water System N
Type of OWTS
n
Sept¡c Tank D Aerat¡on Plant E vault E Vault Privy E Composting Toilet
Et Recycling,Potable Use E Recycling E eit Rrivy E lncineration Toilet
Chemical Toilet E other
Depth to 1s Ground water table Percent Ground SlopeGround Conditions
Effluent Will Effluent be discharged directly into waters of the State? El Yes b(ío
CERT¡FICATION
Applicant acknowledges that the completeness of the appl¡cation is conditional upon such further
nia'ndatory and addit'lonal test and reports as may be requrred by the local health de.partment to be
made andÎurnlshed by the applicant br by the local health department for purposed of the evaluation
of the application; and- the isiúance of the permit is. subject to such -terms and conditions as deemed
necessary to insuie compliance with rules ánd regulations made, information and.reports submitted
herewith'and required tö be submitted by the apþlicant are or will b.e rep.resented to be true and
correct to the belt of mv knowledge and belief and are designed to be relied on by the local
department of health in'evaluatinf the same for purposes of issuing the. permit apnlie.d for herein. I
further understand that any falsifiãation 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 t have read and understand the Not¡ce and Certification above as well as
have provided the required information which is correct and accurate to the
ç*R R=*l^r 4
best of mv
l,.l
knowledge.
417
Property Owner Print and Sign
7?7'oo,
Date
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OFF¡CIAL USE ONLY
Special C.onditions:
Fees Paid:e.?TPerk Fee;ls0-rota¡ Fees: L73-Perm¡t Fee:l'lþ-
lssue Date:
5,fr(o.JT ""'^""#2.ÐSept¡c Perm¡t:*TÍ- qml,Buildine Permitaw- qbqs
BUILDING/ PI.ANNING DIVISION:
Date