HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPTICATION
RS ity Development Department
108 8th Street, Suite 401
AUG CI B ?tlï Glenwood Springs, co 81601
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tr AlterationNew lnstallation
Dwellin il Transient Use tr Comm lndustrial tr Non-Domestic
E other Describe
Property Owner:
Mailing Address:Ø{{
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hiEmail Address
contractor: -IR\¡fttfg( (åÀSbn!4\N\
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Phone:
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Mailing Address
EmailAddress:
I
Was an effort made to connect to the Community Sewer System:
Phone:
0r a
o c a
NoNa- arwlørü?O
b.
a
s
Assessor/s Parcel Number:
Distance to Nearest Commun¡ty Sewer System:N/n
Building or Service Type:
Engineer:
Job Address:
Lot _ Block _
#Bedrooms: Garbage Disposal(Y/N) Y
Mailing Address:
Email Address:
Septic Tank Aeration Plant Vault E Vault Privy l-J compostingToilet
n other
E Pit Priw lneineratíon ToifetE Recycling
Type.of OWTS
E chem¡eal To¡let
Recycling, Potable Use
Ground Conditions Depth to lst Ground water table
-[{
th Percent Ground Slope -aQÇ
Well
Other
El Above Ground DispersalFinal Eisposal.by
E Spring fl Stream or Creek El cistern
Sand Filter
Absorption trench, Bed or Pit E Underground Dispersal
Wastewater PondEl Evapotranspiration
Water Source & Type
Effluent
E Community Water System Name
YesWtll Effluent be disrharyed directly into waters of thÈ State?No
icgniïfilåTï'il
Aoplicant acknowledges that the completeness of the application is conditíonal upon such further
;iai'¡;îów;ñláOOitioñal rest and reþorts as may be required by the local health de.partment to be
';;Ë;;å'f;in¡rf'ãã nlt¡'e appticant br by the loðal healih depaitment for purposed of the evaluation
¿¡it1ê ãópúãatìon; àndtüe- ¡iíüance of the permit is. subject to such terms and conditions as de emed
¡äil;yi;lnsuie co*pt¡rnlà with rules ånd regulations rnade,.i¡forrnation and.reports submitted
neiãwiifr'and required tå ¡e iu¡mttted by the-apllicant are or witl b.e represented to be true and
ioir*it-ioit'rã ¡e1ì of mv knowledge and 'belief ånd are designed to be relied on by the.local
d;;;rr"ì;,ii]1n.åtirrtn'evaiurtlñs'ihesameforpurposesoîissuingthe.permitâ.pple.dforherein, I
frïh;;';;d;;itänäîr,at ãny fais¡tiiation or misreþresentation maylesuli in the denia.l of the
;piiËåtid;i-ievocàtion of any permit gränted based upon sald application and legal action for perjury
as provided by law.
I hereby acknowledge that I hava read and understand the ltlot¡r€ and Certification absve as well as
have provlded th* required ls correct ând ãccurate to the best of my knowledge.
6 / ¿t/ ¿úr7
Owner and Date
PD.17þ.oo¡ ccr tî
Special Êondltionsl
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SiÍnad Approval [tãtr
4 t4 2017