HomeMy WebLinkAboutApplicationGaffield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICAT¡ON
- -, -' ¡."'i :. li
:i Þìq ;H,!
FN
LÙ
$
JUil 0 6 1011
munity Development Department
108 8th SÍeet, Suite 401
Glenwood Springs, CO 81601
. a ra i! .r i i i ,. ;riJil l':' (9701945-8212
', jnì iloii i.,' :',i i,t., lit" ii'ì irþww' ga rfi el d-cou ntv'com
tr Alteration tr RepairNew lnstallation
WASTE TYPE
tr Comm./lndustrial tr Non-DomesticEl Dwelline E Transient Use
E other Describe
TNVOTVED PARTIES. ,
Property owner: Uhn S Of l cY9o 4 Phone:
Mailing Address
EmailAddress:
0 ñ¿-tl zl
CoØf+{ls<c
Contractor:Phone: (?7o I 9+U ç
Mailing Address:
¿?'
EmailAddress:cl,1 (tÇ44cÊnrtû r-t(@ 4 þn4i/rq
Engineer:Phone:2
Mailing Address:
EmailAddress:
W q( þonJqÌ (a 6{3
v ÒVk1
PROJECT NAME AND TOCATION
Job Address:
-02 0 t#hnwoo| h,,lhw rot l5 Brock-Assessoy's Parcel Number:
Building or Service Type:Åt¡tl(th n #Bedrooms: L Garbage Disposal I
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
t
s
Type of OWTS { SeRticTank E Aeration Plant E Vault E Vault Privy tr Composting Toilet
E Recycling, Potable Use El Recycling EI tit erivy E lncineration Toilet
E Chemical Toilet E other
Ground Conditions Depth to lst Ground water table
t
Percent Ground Slope
Final Disposalby trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type Awell E Spring El stream or Creek El cistern
E Community Water System Name
Yes Now¡ll be discharged directly into waters of thent
'.1 t{ ìì11:l ll 'il f:lrli\irr i{:ìl [\ i
I hereby acknowledge that I have read and understand the Not¡ce and Certification above as well as
have the required information which is correct and accurate to the best of my knowledge.
0 t
Property Owner Print and Sign Date
l>.4 o-vt I trtvq
Special Conditions:
Fees Paid:
L
Total Fees:Perk Fee:
îwuPermit Fee:
Balance Due:lssue Date:
ö
it:PermBuildingPerm¡t
BLDG DIV:6f t¿ løry
DATEAPPROVAL