HomeMy WebLinkAboutApplicationGørfield Counþ ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
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Department
Street, Suite ¡101
Springs, CO 81601
945-8212
WPE OF CONSTRUCTION
Phone: ( gzo )
Mailing Address:10325 County Rd 331 , Silt, CO 81652
Email Address:kkoconnellTg@ gmail.com
tr Alteration
tr Non-Domestictr Comm./lndustrialE Transient Use
tr RepairNew lnstallation
WASTE TYPE
I Dwel
t other Describe
Phone:Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
was an effort made to connect to the Commun¡ty Sewer System
Phone: (
Job Address:TBD
Building or Service TYPe:Residential
. N/A
Assessot's Parcel Number:2401-342-00-138
N/A
co 81652Rd 331 , silt,
Distance to Nearest Community Sewer System
PROJECT NAME AND TOCATION
#Bedrooms: 3 Garbage Disposal(Y/N) Yes
Text Lot Block
E vault PrivyE VaultE Aeration PlantSeptic Tank
E lncineration Toilet
I ComnostingToilet
E eit RrivyE Recycling, Potable Use
E other
E Recycling
E Chemica¡ To¡let
Type of OWTS
Percent Ground SlopeDepth to 1* Ground water tableGround Conditions
E Above Ground DisPersalE Underground DisPersalE Absorpt¡on trench, Bed or Pit
El Sand Filterìlìrastewater PondE Evapotransp¡rat¡on
E other
Final DisposalbY
E CisternE Stream or CreekE SpringI WellWater Source & TYPe
fl CommunitY Water SYstem Name
Will Effluent be discharged directly into waters EYes INoof the State?Effluent
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
;åilËiil;;A-;äãñiffiil"si-an¿ ,"þorts as may be required by the local healttr de.pa.rtment to be
ffiäËî;å'f;;irî;î bîiî'"äi]Ë;iãi nv fñ* l,ré"1 healih department for pu.rposed.of the evaluation
of the apptication; ,nit-r,ã¡rí,iánãe of thtí úãit"¡t ¡r subject to such terms ahd òonditions as deemed
necessary to insure d;;ñË-r''th rur.s ån¿ iégulatioîs made,.information and reports submitted
herewith and require¿ iã'urj'r-J#ìti;ã btih; róTli.rnt are or will be rep.res.ented to be true and
correct ro the u"rt oti"îËnïñrãïää-ã"J'¡ét¡ãrån¿ are designed to be rélied on bvthe.local
deoartmentofhealthinevaluatingthesamàioipurposes.oTissuingthe.permita.RRliedforherein' I
i"iñLi';;å";;tä""äîr'åï ãnv tujiiiìËution or misreþreientation mav result in the denial of the
apptication o,' ,."uo.riìä;;i;;t p¿rmit graniä uãsããup"n said ápplication and legal action for perjury
as provided bY law.
I hereby acknowtedge that I have read and understand the Not¡ce and certificat¡on above as well as
have provided the required information which is correct and accurate to the best of my knowledge'
t<
Prope owner Print and S¡gn Date
.c
OFFICIAL USE ONIY Sltsile tr
Special Conditions:
Paid:oôTotal Fees:Ao627<PerkFee: ^A$/fr\*Fee:oÔ
Due:@Balancevlssue Date:6ttRSeptic Permit:
r'æT- ÕASL
Building Permit(zllç--.ff,SO
BUILD¡NG/ PTANNING DIV¡SION
Signed Approval Date
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