HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
RECEIVED 108 8th Street, Suite 401
Glenwood SPrlngs, CO 81601
MAY 1 I 2018 (970194s-82L2
www.garfield-countv.com
GARFI ELD COUNTY
COMMUNITY
ITPE OF CONSTRUCTION
lnstallation Alteration tr Repair
WASTE TYPE
Et Dwelline E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
INVOTVED PARTIES
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Phone:
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Email Address:
Property Owner:
Mailing Address:
Email Address:
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Phone:
á*r^a a^+Mailing Address
Contractor:
Engineer: Phone:
Email Address:
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Mailing Address
PROJECT NAME AND TOCATION
Was an effort made to connect to the Community Sewer System:
Garbage Disposal(YrÐ-
b.lot _ Block
#Bedrooms:
Job Address:
Assessor's Parcel Number:
Building or Service Type:
D¡stance to Nearest Community Sewer System:
E Vault E Vault Privy Compost¡ng To¡lettlp SepticTank E Aerat¡on Plant
E Recycling E eit erivy E lncineration ToiletE Recycling, Potable Use
E other
Type of OWTS
E Chemical Toilet
Percent Ground SlopeGround Conditions Depth to lst Ground water table
llS underground Dispersal E Above Ground DispersalE Absorption trench, Bed or P¡t
E Wastewater Pond E Sand FllterE Evapotranspiration
Final Disposalby
E other
E Spring E Stream or Creek E Cistern{ weltWater Source & Type
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State?E Yes lRno
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional Ypgn such further
nìandatory and addiiional test and reþorts a.s Tay be required by the local health de.partment to be
made and'furnished by the applicant ôr by the local health department for pu.rposed.of the evaluation
of ihe application; and the isöüance of the permit is.subject tosuch terms and conditions as deemed
necessa'ry to insuie compliance with rules ánd regulations made, information and.reports submitted
herewith'and required tô be submitted by the_apþlicant are or will be repres.ented to be true and
correct to the belt of mv knowledge and belief and are designed to be relied on by the local
department of health in'evaluatinã 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.
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I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
Property owner Print and Sign Date
oFFrcrAL usE oNLY .Pâü{ S/tr, I t8 Îff.-ð:sÞØ
Special Conditions:
'ilþ"i- oo 'S;",+".*'då.s*Fees oCI
Building Permitt),rl Seotic Permit:stsPr-9.l(ø lssue Date:
...5. ltl ,l8 "''nå;;'oo
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BUILDING/ PLANNING DIVISION
Date