HomeMy WebLinkAboutApplicationGørfield County
Development Department
ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
New lnstallation tr Alteration tr Repair
WASTE TYPE
I Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
b other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Phone: t7 lA I -7'tk LI'I JçT
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Contractor¡one: I I
Mailing Address:
Email Address:
Engineer: Phone:(
Mailing Address:
Email Address:
PROJECT NAME AND TOCATION
Job Address:l<-lJ c
Assessor's pa rce I N u m be r, LlTllbÐtlt s"a.Lot Block
Building or Service Type:'Z6sr t'nkl,#Bedrooms:Garbage Disposal(Y/N) L
Distance to Nearest Community Sewer System:-14
Was an effort made to connect to the Community Sewer System:
- ^/O
Type of OWTS A Sept¡cTank E Aeration Plant E Vault E Vault Pr¡vy tl Compost¡ng To¡let
E Recycling, Potâble Use E Recycling E P¡t Pr¡vy E lncinerationToilet
E Chemical Toilet E other
Ground Cond¡t¡ons Depth to lst Ground water table Percent Ground Slope
Final Disposal by KAbsorption 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 Iwett E Spring E Stream or Creek E Cistern
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State?E Yes Fto
Applicant acknowledges that the completeness of the applicat_ion is conditional Vpgn such further
niandatory and addit'lonal test and reports as may be required by the local health de.partment to be
made and'furnished by the applicant ôr by the local health department for purposed of the evaluation
of the application; and'the isiúance 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 tó be submitted by the applicant are or will be repres.ented to be true and
correct to the belt 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 applie.d lor herein. I
furiher understand that anyfalsifiıation or misrepresentation may result in the denialof the
application or revocation oi any permit granted based upon said application and legal action for perjury
as provided by law.
CERTIFICATION
I hereby edge that I h
have the
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V;I
nt and Sign
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read and understand the Notice and Certification above as well as
ation which is correct and accurate to the best of my knowledge.
Date
OFFICIAL USE ONLY
Special Conditions:
2Tà,WTotal Fees:Fees Paid:fta.0oPermit Fee:
12'7æ
Perk Fee:
150.oo
Balance O"",
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Sept¡c Perm¡t:
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lssue Date:\.25, lgBuilding Permit
AtlÆ"-âlW
BUILDING/ PLANNING DIVISION:
Signed Approval
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