HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8'h Street, Suite 401
Glenwood Springs, CO 81601
(9701945-8212
www.ga rfield-cou nty.com
TYPE OF CONSTRUCTION
E lrlew lnstallation tr Alteration tr Repair
WA$TE TYPE
EzDwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
P Phone
¿
Email Address:o
Contractor:Phone:(I
Mailing Address
Email Address:
Engineer:a¿¿e è Phone:
Mailing Address
Email Address:
nÁ.A
PROJECT NAME AND TOCATION
Job Address ï
Assessor's Parcel Number Lot Block
#Bedrooms: J Garbage Disposal(Y/N) ûø
/ó *rr\-s
Building or Service Type:
Distance to Nearest Community Sewer System
Was an effort made to connect to the Commun¡ty Sewer System 4û
Type of OWTS ,lseptic Tank E Aeration Plant E vault E Vault Pr¡vy n compostingTo¡let
E Recycling, Potable Use E Recycling E Pit Privy E lncineration Toilet
E Chemical Toilet E other
Ground Conditions Depth to 1st Ground water table Percent Ground Slope
Final Disposal by E Absorption trench, Bed or Pit E(Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type tr Well E Spring E Stream or Creek E Cistern
E Community Water System Name Fan*¡t¡t+<c /[I
Effluent Will Effluent be discharged directly ¡nto waters of the State? E Yes AE[ruo
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional r¡pgn such further
"iui6ãiowãnla¿ãlt"¡on"l
test and reþorts as may be required by the local health de.partment to be
rãiËlü¿'füriiished by the applicant br by the loóal hcalth department for pu.rposed.of the evaluation
äf tt'ã ãóplìãalión; ánA'tne isiüance of thé permit is. su.bject to such terms and conditions as deemed
necessa'rv to insure compliance with rules ánd regulations made, information and reports submitted
üãi"*-ii¡"rnO rèqulre¿ tò be submitted by the -apþlicant are or will be rep.resented to be true and
äıir"àfioì¡é Uìü of mv knowledge and belief ánd are designed to be relied on by the.local
ããórñ-"ìã'it óf neãnn in'evaluatin[the same for purposes oÍ issuing the permit a.pplied for herein. I
i*iñ"i ,ñ¿"istáñO tt'at any falsif'rıation or misreþre'sentation m.ay result in the denial of the
;;òii*t'r" ór iãvócation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge
have provided
Property Owner nd Sign
and understand the Notice and Certification above as well as
to the best of my knowledge
*Ò-r
Date
P6,c rrì
s 121 but
ú.yI '
OFFICIAL USE ONLY
Special Cond¡tions:
Total Fees:Perk Fee:Permit Fee:
Balance Due:lssue DateSept¡c Perm¡t:
f-
Building Permit
BUILDING/ PLANNING DIVISION
Signed Approval Date