HomeMy WebLinkAboutApplicationGurfteld County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
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JUL 2 4 2018 Glenwood springs, co 81601
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WASTE WPE
TYPE OFCONSTBUCTION
New lnstallation E Alterat¡on ftrRe
Ef Dwelling E Transient Use tr Comm ndustrial tr Non-Domest¡c
E other Describe
INVOLVED PARTIES phone:fl1l I ff Tb- sltÐProperty Owner
Email Address:Ior^Vr-
Mailing Address: 3qg %to si /È co tÌusz
Phone: 6t0 ¡ ZSS-î r, O
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Contractor:
Email Address:
Mailing
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Address: lg)0 O U
Engineer: fJ W7 Phone:
667 Cdppø¿ ¿ß^/yUtv jr¿ourt t¿7. Ca
7
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Mailing Address:
Email Address:
PROJECÍ NAME AI¡D LOCATION
Was an effort made to connect to the Community Sewer System:
Job Address:
/
Lb Ll J-h¡¡s"lrøti g. lf_ (,Ð VI{¿S>
Assessor's Parcel Numb.r, Al'J q\1?.0.loo3sub.
(Lt ilqr*ì *lBuilding or Service Type:
Distance to Nearest Community Sewer System:n:LEJ -l-ttttLÊî- Lú¡tr, t*/î
E vault E Vault PrirryE Sept¡cTank E Aeration Plant l-l CompostlngTo¡let
E Recyding, Potable Use El Recycling El Rit ariny El lncinerat¡on Toilet
E other
Type of OWTS
E Chem¡calTo¡let
Ground Conditions Depth to 1st Ground urater table
-
Percent Ground Slope
p Absorptlon trench, Bed or Pit El Underground Dispercal E Above Ground Dispersal
El Eyapotranspirat¡on E Wastewater Pond E Sand Fllter
Final Disposalby
E Other
tr Well E Spring E Stream orCreek E cisternWater Source & Type
E Communíty Water System Name
Effluent WillEffluentbedischargeddlrectlyintowatersofthestate? E Yes Dl tlo
i CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of health in evaluating the same for purposes of issuing the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
t hereby acknowledge that I have read and understand the Notice and Certification above as well as
red information which is correct and accurate to the best of my knowledge.
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Property Owner Print and Sign Date
OFFICIAL UsE ONLY
Special Conditíons:
Permit Fee:
örz-g,DÕ
Perk Fee:
€.v't4
Total Fees:
Brze.oo
Fees Faid:
J?3 , [ù
Building Permit
BLRE 53?2
Seotic Pblmitrsçt^<s1 i lssue Date:slt*l tk Balance Due:
ø
BUttDtNG/ PLANNING DtvtstoN øØlæø
Signed Approval Date