HomeMy WebLinkAboutApplicationGørfield County
E Alteration trRe trNew lnstallation
tr Comm./lndustrial
El Other Describe
ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
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RE cE NE úom m u nitYrDeveI oPrncntDePa rtm e nt
TE.B t 6 ?s18
Glenwood Springs, CO 81601
lp7ol945-82t2
rEtÞ t ouN
OF CONSTRUST¡ON
WASTE TYPE
Dwelli E Transient Use tr Non-Domestic
INVOTVED PARTIES
Property Owner:
Mailing Address:
Phone
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Email Address:t¿t¿ç mf //ã P¿;f"ttlno
Mailing Address:
Email Address:
)Phone:(Contractor:
Engineer: Phone:(
Mailing Address:
Email Address:
Type of OWTS
E other
ult E Vault Privy
E P¡t Pr¡w E lnc¡nerat¡on Toilet
Sept¡c Tank E Aeration Plant EVa
E Recycling, Potable Use E Recycling
E Chemical Toilet
n CompostingToilet
Percent Ground SlopeGround Conditions Depth to lst Ground water table
E Above Ground Dispersal
E Wastewater Pond E Sand Filter
Absorption trench, Bed or Pit E Underground Dispersal
E Evapotransp¡rat¡on
E Spring
E other
E Stream or Creek E CisternWater Source & Type
Effluent
Well
PROJECT NAME
Job Address:
Assessol's Parcel Number:
Final Disposalby
Sub.Lot Block
Garbage Disposal(Y/N)-Building or Service Type #Bedrooms:
Distance to Nearest Community Sewer
Was an effort made to connect to the Community Sewer System:
E Community Water System Name
Will Effluent be discharged directly into waters of the State? E Yes
Applicant acknowledges that the completeness of the application is conditionalgpgn such further
nia'ndatory and addiiional test and reþorts as may be required by the local health department to be
made and'furnished by the applicant ôr by the local health department for pu.rposed of the evaluation
of the application; and the isiúance of thd permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance with rules ànd regulations made, information and.reports submitted
herewith'and required tö be submitted by the -apþlicant are or will b.e rep.res.ented 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'evaluatinf the same for purposes of issuing the permit applied f_or herein. I
further understand that any falsifiıation 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 Notice and Certificat¡on above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
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Property Owner Print and Sign Date
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Special Conditions:
Fees Paid:L:rv -PerkFee:
lro -
rotarFees: T7n -Perm¡t Fee:
lTv -
Balance Due:
a
lssueBuilding Permit
Ç
Sept¡c Permitl
Fsn
D"t" -C,/d
BUILDING/ PLANNING DIVISION: