HomeMy WebLinkAboutApplicationSCANNED
JUL o 3 zots
"'"t"i:.rï:ï'r:,"¿ïåÎår,GARFTELD COUNTY PTols4s-821,2
COMMUNITY DEVELOPMENT www.sarfield-countv.com
RECEIVED Community Development Department
r TYPE OF CONSTRUCTION
tr New lnstallation
, WASTE TYPE
Dwell E Transient Use
Alteration R_e-paf¡ -
tr Comm./lndustrial tr Non-Domestic
INVOTVED PARTIES
Property Owner:
Mailing Address:
EmailAddress: fñôt¿-@ IZSCWÈo(-t< , Cenr.r
Phone:ð a IÈ¡ G"s &'6o\
Engineer:Phone:
Mailing Address:
Email Address:
Gørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
{owrs}
PERMIT APPLICATION
E Other Describe
contractor: C-A-€-LA 09T B€e tr Phone: (d{-lo ) 3,est 5z-Sel
P{ d,".r}:c^À--Le
et6L3
ceI1) G*-.r Þrr.rqMailing Address:
Email Address:
Ztc'ç1f{R..o tt Pl=r:
p SentlcTank E Aerat¡on Plant E Vault E Vault Prlvy ! CompostingToilet
E Recycling, Potable Use E Recycling E Pit Privy E lncineration Toilet
El Chemical Toilet E Other
Type of OWTS
Depth to 1r Ground water table r¿ / raGround Conditions þlAPercent Ground Slope
El Absorption trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E wastewater Pond E Sand Filter
Final Disposalby
$. other
F\rvell E Spring E Stream or Creek E CisternWater Source & Type
E Community Water System Name
Will Effluent be discharged directly into waters of the State? E Yes - 14 ruoEffluent
PROJECT NAME AND TOCATION
Job Addressr
Assessor'sParcelNumber: ?21$!g-3gg-!--14 SuU.Ç.*o.^\t.\t fàt *rot J Block-
t
Building or Service Type:v'
Distance to Nearest Commun¡ty Sewer System:
#Bedrooms: \ Garbage Disposal(Y/N) t'
U¡ê
Was an effort made to connect to the Community Sewer System:Si c)hf fur^i l^,b\4
CERTIFICAT¡ON
Applicant acknowledges that the completeness of the application is conditiona! Ypgn such further'rffi'à-"útãnU
aOO¡tional test and reþorts as may be req'uired by the local health de.partment to be
rãäã rî¿'fürnist,èO Uv the applicant ôr by the loóal healih department for pu.rposed.of the evaluation
öi1Ëã;óËlùåt¡on; áncíttre ¡iéüance of thé permit is.subject tosuch terms and conditions as deemed
necessarv to insuie compliance with rules ánd regulations made, information and reports submitted
üãiã*-¡itr'rnã iequlre¿ tö be submitted by the_apÞlicant are or will b.e rep.resented to be true and
lıir"ðiìoìtrà biii of my knowledge and belief and are designed to be relied on by the.local
ı|jrfiili ói¡ãàñtr in'evaluatin[the same for purposes oi issuing the.permit applie.d for herein. I
i*iñäi rñ¿èistáñ¿ tt'at any falsifiıation or misrepresentation may result in the denialof the
"pıiicrtio"
óirevócàtion of any permit granted b'ased upon said application and legal action for perjury
as provided by law.
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.
\
nt and Sign Date
-7
Po,'/ Á/75-t,
OFFICIAT USE ONLY
+h 6A?A-054ø-6b+l
Special Conditions:
Uttt
PaidFees,t-75TFees:Perk Fee:Fee aô
Balance Due
€8
lssue Date:
5Buildlrg Permit
BUTTDtNG/ PLANNING DlvlsloN
Signed Approva
sfuþotø
Date