HomeMy WebLinkAboutApplicationGurfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
_ Community Development Department
RECEIVED 1088ü Street, Suite4ol
JAN 1 b zot8 u'""*i3loìä?:;'r:181601
F.î,i5.iF|3'9'?"'ilhry
TYPE OF CONSTRUCTION
New lnstallation E Alteration tr Repair
WASTE WPE
tr Dwelling E Transient Use Er Comm./lndustrial tr Non-Domestic
El other Describe
INVOTVED PARNSS
Property Owner: Red Barn Ranch Phone: ( q¿q )582-5960
Mailing Address: 345 Mirl Valley T nne -
Email Address:
Contractor: Haves Construction Phone:(qzn ) 618-6525
Mailing Address:
Email Address:
Engineer: Molrnfain CrossF.ngineering Phone: ( 970-9t15
Mailing Address:
Email Address:
PROJECT NAME AND TOCANON
Jeþ [6]¡l¡sss¡ sas
Assessor's Parcel Number: 2181-063-00-135sub.lot _ Block _
Building or Service Type:Commercial sBedrooms: N/A Garbage Disposal{Y/N} N
N/ADistance to Nearest Community Sewer System
Was an effort made to connect to the Community Sewer System:
Type of OWTS ElrEept¡c Tank E Aerat¡on Plant E vault El vault Prlny f] comRostingToilet
El Recycllng Potable Use E Recycllng E Pit Privy E lndneration Toilet
E chemical To¡let El other
Ground Conditions Depth to l"t Ground water tablet Percent Ground Slope
Final Dlsposal by ElAbsorption trench, Bed or P¡t El Undergrotmd Dispersal E Above Gror,md Di¡persal
El Evapotranspiration E Wastewater Pond E Sand Filter
E other
la
Water Source & Type Ifwetl E Spring E Stream o¡ Creek E cistern
E Community Water System Name
Effluent Wll Eff,uent be discharged dlrectly lnto waters of the State? El Yes El luo
Applicant acknowledges that the completeness of the appl¡cation is conditional upon such further
nidndatory 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
fuither 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 Not¡ce and Certification above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
Owner Pr¡nt and S¡gn Date
&
b
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Special Condltions¡
Total Fees:
*tqz.@
Fees Paid:
4 legloSrä*Perk Fee:trkß
Balance Due:w.æBullding Permlt\{lA Septic Permlt:
twr_À5¡374.ot -t -18,
lssue Date!
/MBUID|NG/ PTANNTNG DrVrSrON:
at
Date