HomeMy WebLinkAboutApplicationGarfi.eld County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
REC munity DeveloPmcnt DePartment
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TYPE OF CONSTRUCTION
Alterationllationtr New trRe r
TYPEW tr Non-Domesticlndustrialtr commE Transient UseDwellin
E other Describe
INVOTVED PARTIES
(-f
Phonel
Email Address:
Property Ownerl
Mailing Address:
(
Phone:Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
Phone
Building or Service Typer fBedrooms: 3 garbage Disposal(Y/N)7
D¡stance to Nearest Community Sewer Systemt
-
the Community Sewer SYstemWas an effort made to
Assessor's Parcel Number:
Job Address:
sub.
-
lot
-
Block
-
E Vault Privy fl Composting To¡letE VaultE Aeration PlantSeptic Tank
E Pit erivy E lncineration ToiletE RecyclingEl Recycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to lst Ground water tableGround Conditions
E Above Ground DispersalE Underground DisPersalAbsorpt¡on trench,Bed or Pit
E Sand FilterE Wastewater PondE EvapotransPiration
tr
Final Disposal by
E CisternE Stream or CreekWellE Spring
E Community Water System Name
Water Source & TYPe
NoE YesWill Effluent be discharged directly into waters of the State?Effluent
PROJECT NAME AND TOCATION
Aoplicant acknowledges that the completeness of the application is conditionalupon such further
îi#å";iå';"riliåäãìtiàñjí ù:i and refort' riããv iie *iuiiéo ¡v the local health de.pa¡_tment to be
ffiffiTåi;'.iìrl;î Ëi tï" r-pptü"iã¡ nv ine lóéai tre.atitr department for purposed of the evaluation
ääñãäóËlìäåt¡ı'i; ã"dt'Éã¡iíüá'r'c" ôitnË pãrmit is.su.bject to such terms and conditions as deemed
necessarv to insure .oróiáir.ä-*itL ruìeJ änO regulatioîs made, information and.reports submitted
Ëärî|"";';ı;ìrã:.ilı uË Jruritt"¿ by the-apþlicant are or will be represented to, be-true and
lıiöàt'iãirrã U-dsi ot mîfn-Ñle¿áe an¿'bel¡ef ànd are designed to be relied on by the,local
ããöãrt',iã,ii óirriånrr ¡n'evaiuàtìñäitré same for purposes oi issuing the.permit a.pplied for herein' I
i,;iËi'ñà;;;täräîÉåï ãÀv tãii¡t¡iation or misreþreientation m.ay result in the denial of the
;îÈË;t'r;óiiðuıcät¡on oi añv pérrit granted based upon said a.pplication and legal action for perjury
as provided by law.
f i.ì :l iiìt ll ll il l(r ¿^,¡ 11 1¡r¡) ri
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have the information which is correct and accurate to the best of my knowledge.
Print and Sign
Special Conditions:\)w-H t ,
ØPald:'*å'Ë' *Perk Fee:
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Fee:oôS.
"ï"6'.9'o..ü."äilSsäptftÞermit:qtr\¡ç-BttL4iBuilding Permitfìçç -defo
Dete
BUILDING/ PTANNING DIVISION:
Signed
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