HomeMy WebLinkAboutApplicationGarfteld Counly ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
nity Development Department
108 8th Street, Suite 401
itAY 1 ? uolT
Gr"n*T;i;ä:ï,rï 81601
:. www.garfield-countv.com
TYPE OF CONSTRUCTION
New lnstallation tr Alteration tr Repair
WASTE TYPE
Dwelli E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
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Phone: ( ql0 ) q8-ì 5132
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Contrector:Phone: ( )
Mailing Address:
Email Address:
Engineer: Aì\ .Vi\/ÎaL )¿phL Phone:(qO ],36 q SZSI.
Pn.t).,a^r) n)o Rlbz?Mailing Address:
Email Address:
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PROJECT NAME AND TOCATION
Job Address:
Assessor'sParcel Number: 2tA lo q nt24 b. c-CP Lot / Block-
Building or Service ¡vpe: i.? 4^d¿^n^âL #Bedrooms: Garbage Disposal X. Distan.e
Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS El Septic Tank E AeÌation Plant E Vault E Vault Privy tr Compost¡ng To¡let
E Recycling, Potable Use E Recycling EI Pit Privy E lncineration Toilet
E Chemical Toilet E other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
Final Disposalby E Absorption trench, Bed or Pit E Underground Dispersal E Above Ground D¡spersal
E Evapotranspirat¡on E Wastewater Pond E Sand Filter
E other
Water Source & Type E Well E Spring E Stream or Creek E Cistern
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes tr No
Applicant acknowledges that the completeness of the application is conditiona! Vpgn such further
niandatory and additional test and reports as may be required by the local health de.pa_rtment 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
necessaiy 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 belt 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.
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Special Conditions:
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Balance Due oÔ#^.Septic Perm¡t:strç\-u?tlô lssue DateBuilding Permit
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BUILDING/ PLANNING DIVISION:
Signed Approval Date
CERTIFICATION
I here
have ed
I have read and understand the Not¡ce and Certification above as well as
information which is correct and accurate to the best of my knowledge.
LÔ1
Sign Date
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