HomeMy WebLinkAboutApplicationONSITE WASTEWATER
TREATMENT SYSîEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th street, Suite 401
Glenwood SPrings, CO 81601
ltg7ol945'82t2
www.qarfield-counW.com
E AlterationNew lnstallation
tr Non-Domesticdustrialtr CommE Transient UseDwelli
E Other Describe
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Phone
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CIT ct
Email Address:
Property Owner:
Mailing Address:
Contractor:
Email Address:
Engineer:
Email Address:
Was an effort made to connect to the CommunÍty Sewer System¡
Phone: (
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Phone
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Disposal(Y/N) ilA-fBedroomsr -? Carbage
PROJECT NAMË AND{OCATION
Mailing Address:
Distance to Nearest Community Sewer System:
Mailing Address:
Assessor's Parcel Number:
Building or Service TYPe:
l¡rJob Address¡
El vault Privy Composting ToiletI Septic Tank Aerat¡on Plant V¿ult
E eit Rrivy lncineration ToiletE RecyclingE Recycling, Potable Use
n chemicâl To¡let
Type of OWTS
Percent Ground SIopeDepth to 15t Ground water tableGround Conditions
E AboveGround DispersalE Underground D¡spersal{ nbsontion trench, Bed or P¡t
El wastewater Pond
Final Disposal by
Water Source & TYPe well
E Evapotransp¡rat¡on E Sand Filtêr
E other
or creek E cisterntr spring E stream
E Community Water System Name
Effluent W¡ll Effluent be discharged directly ¡nto waters ofthe state? El Yes .{
Aoplicant acknowledges that the completeness of the application is conditional gPon such further
;iJ;¡;liår;;d àädttiı;íllìi rno t.öorts as ñ.rãv Þç *gyired bv the local health de.partment to be
ffiliË:#åi;ilìrî:îïiä;.;;iiiäiãi uî iñó uðat r'eãÉñ department ror pu.rposed or the evaluation
ääü äóËriðåiiãüiä",í tr.re isåüance of the permìiË su-¡ject to such terms ahd öonditions as deemed
necessary to insure .orËìlå-n.ä-*itr.' ruiäi ånà rãculãiióhJmade, information and reports submitted
herewith and required iå'åi't"r¡äiiiàä biihe apiiièánt are or ,,riill be reoresented tó be true and
correct to the best ot rîrin"ouilääää'äii bäli"t-J'io áiäiãsieïeo to be relied on bv the,local
d;;;ril;"ì óíniãttn in'.uåitiääñåir.rì Jame toipurpóses oi issuing the oermit aoolied for herein. I
i;"ih.,';;å;;;i;;äîüi;;y'f.ì;iiì"diið'ìôi 'iiiei,ieientation
may-resuli in the d'ehial of the
aoolication or revocatio" äf añri ôðimit granteî ¡ãse¿ upòn said ápplication and legal action for perjury
ai þrovided by law'
I hereby acknowledge
have provided the req
that I have read and understand the Notice and Certification above as well as
uired information which is correct and accurate to the best of my knowledge'
1 q
Date,r**pffiÜ /n,{",7 I
Spec¡al Cond¡t¡ons¡
Fees Pâid:Total Fees3Perk Feei lsoPerm¡t Fee:I2
Balance Due:lssue Date:7tSeþt¡c Permit:
34€f .6311Bu¡ld¡ng Perm¡t
wl_ætsBUITDING/ PLANNING DIVISION:
Date