HomeMy WebLinkAboutApplicationGurfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-82L2
www.garfield-countv.com
OF CONSTRUCTION
New lnstallation
WASTE TYPE
E Dwelling El Transient Use
tr Alteration
tr Comm
E Repair
ndustria I tr Non-Domestic
E other Describe
¡NVOLVED PARTIES
Property Owner
Mailing Address
Email Address:
Phone: (4ze ¡ç-
3 :fC er,-å"\\d C.o ttto4l
ët+.e.þ , cc,æL,
Engineer:Phone: (_)
Mailing Address:
EmailAddress:
PRO.IECT NAME AND LOCATION
Job Address:
Assessor's Pa rcel Number:2t uaôëú Lot Block
#Eedrooms: 3 Garbage Disposal(Y/N¡ Y
\-¿:
Building or Service Type:
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:¡fc
Contractor:
Mailing Address:
Email Address:
Phone: I )
E vault Privy n Composting ToiletE VaultEf SepticTank E Aerat¡on Plant
tr Pit Pr¡vy E lncineration ToiletE RecyclingE Recycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to l't Ground water tableGround Conditions
E Above Ground DispersalE Underground DispersalEf Absorption trench, Bed or PitFinal Disposal by
Water Source & TYPe
E Community Water SYstem Name
Will Effluent be discharged directly ¡nto waters of the State?E Yes F tto
E Spring El Stream or Creek
Effluent
CERTIFICATION
*tJJi'ä'J:1tryJ:flffii,"xïiîå"å5å?i:?:',î:l'ffå.iï'ii3i'Bîli:Î3::Ì'fl::i.i'."J'îibtr!:l#liË:i;åi;;jrËäï;iË";;,-pii;"iäi ¡v iñ" toé"i hcalth dcpartment for pu.rposed of the evaluation
of the apptication; ,n¿ tËã¡iíü"nð" oi the Èe;mìi'rs subject to such terms aird ðond¡tions as deemed
necessary to insure d;pli;;¿ä*'th ,r.i"r åni i"gyl"tions made, information and reports submitted
herewith and requireä;ı Ë;briit"ä ¡vihé-aóil¡c.nt are or r,,ri¡lt ue represented to be true and
.ãi*.fi"ir,Ë u-"ti oiäîrini*Ë;ää-ã;i'¡éti"t ånd are designed to be rèlied on bv the local
deoartment of health in'evaiuatin[tt'e same toi purposes.oT issuing the.permit a,pplied for herein' I
i;iñui'uiå";i1,iäiüi ã"v øliìriãrïión or misr"pr"i"ntation may result.in the denial of the
application o'. ,""uo.ri'r*n öÍ rñv p"rmit granied based upon said ápplication and legal action for perjury
as provided bY law'
have provided the req
,5-"-^ .^.å t¡L({': ""ìlc'<
I hereby acknowledge that I have read and understand
uired information which is correct
the Notice and Certification above as well as
and accurate to the best of my knowledge.
4-y- ta
Date
çc'*-i!d Úqtçte i*L{-
! t,rl
Owner Print and Sign
tw, e,u
n
OFFICIAL UsE ONLY
Special Conditions:c.o.tônfrvr^l in v fo finat
Fees Paid:.t o? ,-lrpTotal Fees:Perk Fee""'!'?rb -
Balance Due:lssue
{n
Building Permit
BUITDING/ PLANNING DIVISION:
Signed Approval
W^e bltal?otø
Date