HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
tsþ Com munity Development Department
108 8th Street, Suite 401
Springs, CO 81601
(970194s-82L2
www.ga rfield-countv.com
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TYP/EOF CONSTRUCTION
New lnstallation tr Alteration tr Repair
W TYPE
Dwelling E Transient Use tr Comm./lndustrial Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner
Mailing Address: (o oa o
Email Addressl
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Phone: (1 t1 I ;? 4t -51,ç3
o I
Mailing Address:
Email Address:
Phone:Contrector:
Ensineer: Phone
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System
Building or Service Type:fBedrooms: Garbage Disposal(Y/N)
Assessor's Parcel Number: Sub
Job Address:
Lot _ Block _
E Vault Privy I Comnosting ToiletEf Septic Tank E Aeration Plant E vault
E Recycling E Pit erivy E lncineration ToiletE Recycling, Potable Use
E other
Type of OWTS
E Chemical Toilet
Percent Ground SlopeGround Conditions Depth to lst Ground water table
E Above Ground DispersalE Absorption trench, Bed or Pit E Underground Dispersal
E Sand FilterE Evapotranspiration E Wastewater Pond
Final Disposalby
E other
E Stream or Creek E CisternElzwellE SpringWater Source & Type
E Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes E No
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provi the required information which is correct and accurate to the best of my knowledge.
Lr: t/
Owner nt and Date
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 tosuch 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.
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OFFICIAL USE ONLY
Special Conditions
Permit Fee:w7-Perk Fee:
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Total Fees:2ß-Fees Paid 713-
Building Permitbw*6qT Septic Permit:
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lssue Date:tohln/ lß Balance Due:
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BUILDING/ PLANNING DIVISIoN
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Date