HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
REGElvEftlenwood Springs, co 81601
(97Ole4S-8212
JAN 2 6 2017***;"ro",o-.oun,u..ot
GAR D COU NTY
co
ry
E AlterationE] New lnstallat¡on
WPE tr Non-DomesticE Transient Use tr Comm ndustrialDwelling
E Other Describe
INVOTVED PARTIES¡ ..¡t ___lI__, - ã,
^ _
Property Phone:>U
Mailing Address:
Email Address:
t D.
a
Contractor:Phone
Mailing Address:
Email Address:
Engineer: Phone: (-)-
Mailing Address:
Email Address:
PROJECT NAME AND IOCATION "-'t o^^ I ./, ¡l n^
Job Address:Çfr
Assessor's Parcel Numbe
Building or Service Type:
r:b.Lot Block
Garbage Disposal(Y
D¡stance to Nearest Commun¡ty Sewer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS Septic Tank E Aeration Plant E Vault E vault Priw n Composting Toilet
E Recycling, Potable Use E Recycling E eit erivy E lncinerationToilet
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 Dispersal
E Evapotransp¡rat¡on E Wastewater Pond E Sand Filter
E other
Water Source & Type flwelt E Spring E Stream or Creek E cistern
E Community Water System Name
Will Effluent be discharged directly into waters of the State? E Yes tr NoEffluent
Applicant acknowledges that the completeness of the application is conditional gpgn such further
"irin¿ãowãn¿
aOált"¡onaltest and reþorts as Tay be required by the local health de.partment to be
rãäeãi6'trrn¡sñàà by the applicant br by the loóal he.alth department for pu.rposed.of the evaluation
ääl.tã ãóplìðåäón; ãnd tt'e ¡siüance of thé permit is. su.bject to such terms and conditions as deemed
necessarv to insuie compliance with rules ånd regulations made, information and reports submitted
nãiÑit''rn¿ requìred tö be submitted by the _apþlicant are or will b.e rep.res,ented to be true and
.ıii"ðt-toìté beii of mv knowledge and belief änd are designed to be relied on by the.local
ãééJñi1iãnt ót néann in'evaluatinfthe same for purposes oi issuing the permit applie.d for herein. I
irññ"ì uñ¿"istán¿ that any falsifñation or misreþre.sentation m.ay result in the denial of the
.pıii.rtìón óiievocation oi any permit granted b'ased upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have uired ation which is correct and accurate to the best of my knowledge.
Lo
Owner Print and Sign Date
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Special Conditions:
ØFee@ocPermit Feeö75 {
Balance Due:ío.ØSept¡c Perm¡t:Date:Building
ì\\IA
/¿2:Æt8BUILDING/ PLANNING DIVISION:
Date