HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
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PERMIT APPLICATION
Community Development Department
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108 8th Stree! Suite 401
Glenwood Springs, CO 81601
TYPE OF CONSTRUCTION
tr New lnstallation E Alteration tr Repair
WASTE WPE
tr Dwellin E Transient Use tr Comm./lndustrial tr Non-Domestic
El Othef DeSCfibe warehouseoffice
INVOTVED PARTIES
Property OWnef: Gregg lMackey Phone: (_)
Mailing AddfeSS: Po Box 398, Basalt, CO, 81621
Email Address:"gmack pors" gmackey3@gmail.æm
COntfactof: TallY Ho Construction Phone:(s7o \618 2262
Mailing AddfeSS: 0145CountyRoad225, Rifle, CO 81650
Email Address:tallyhoconst@sopris.net
Engineer:Sopris Engineering, Paul Rutledge and Yancy N¡chol Phone: (s70 ì
Mailing Address:502 Main Str€et, Suile 43, Carbondale. CO 81623
Email Address:prutled ge@sopr¡seng.com
Job AddresS: 0050 county Road I 10, Glenwood Springs, CO
Assessor's Parcel Number: 2127-361-0O-Os2 Crrh Secüon: TlowNhip:7 Rsnge:88of be6lhP.M.LOt bß5md15 BIOCk
Building or Service Type:warehouse off¡ce shop fBedrooms: N/A Garbage Disposal(Y/N)N
Distance to Nearest Community Sewer System:> 1 milê
Was an effort made to connect to the Community Sewer System:N/A
Type of OWTS E SepticTank E Aeration Plant E Vault E vault Privy tr Composting Toilet
E Recycling, Potable Use E Recycling E P¡t Pr¡vy E lncineration Toilet
E Chemical Toilet E other
Ground Cond¡t¡ons Depth to lst Ground wateÌ table '10'Percent Ground Slope 5o/o
FinalDisposalby 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
Effluent Will Effluent be discharged directly into waters of the State? E Yes E ruo
PROJECÍ NAME AND TOCATION
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CERTI FICATION
Aoolicant acknowledses that the completeness of the application is conditional Ypgn such further
;äiåä;;;;;iåäditññ;iteìianã reþorts as may be required by the local healttr de.partment to be
il;;;;;å'f;;ìrñä-bt th" ãppiicant br by the loéal he.alih department for pu.rposed.of the evaluation
äi t¡,ã ãá"1ìã"lionrrn dit'trã¡ií,Iãnc" oi thË permit is subject to such terms and conditions as deemed
;;äilffi;l;*;" ¿;;óffièî''th ¡ules ånd regulatioïs rrìäde, information and.reports submitted
üãià,i""iii"".¿ iãór¡r.O lı bã iubmitted by the apþlicant are or will be representgd t9 be-true and
äòit"åfioì¡'è ¡Ëü oi mv tnowle¿ge and bel¡ef ánd are designed to be relied on by the.local
ı|¿ñ'¡ili ıi¡rãalifr in'evaÍuat¡nãthe same for purposes oi issuing the. permit a.pplie.d for herein' I
f;ih;;'ü;d;;stãñäïÉai ãny tátsitñation or misreþre'sentation m.ay result in the denialof the
àîËiiätî". óiiãuó.ãtion ôi anv permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Not¡ce and Certification above as well as
have provided the information which is correct and accurate to the best of my knowledge.
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Owner Print and Sign Dete
\laðllaOFFICIAL USE ONLV
Po,xTE,psPLcîo
Special Conditions:
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Paid ØFees6Total Fees:oOPerk Fee:Fee:oo
Be oolssue Date:Septie Permit:Building Permit
//tÉg,rtBUILDING/ PLANNING DIVISION :
DateSigned