HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrsl
PERMIT APPLICATION
tr Alteration tr Repair.Èil. New lnstallation
tr Non-DomesticEI Transient Use
WPE
tr Comm./lndustrialDwelli
E other Describe
INVOTVED
Property Owner
Mailing Address
Phone:
Email Address:
Phone:
Phone:
8
u1Engineer: ,re.t.. 6co*s
Contractor:
Mailing Addressr
Email Address:
Mailing Address:
Email Address:
Was an effort made to connect to the Community Sewer System:
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PROJECT NAMF ÀNfI IfI¡
D¡stance to Nearest Community Sewer System:
#Bedrooms:
Block
Garbage Disposal(Y/Nl À)
Job Addressl
Assessor's Parcel
Building or Service rvp", 1o: f d O n \\ Crr. \
El Vault E Vault Prlvy l-l Composting ToiletTank{sentic E Aerat¡on Plant
E lncineration To¡letE Reçycling E P¡t Pr¡wE Recycling, Potable Use
E otherE chem¡cal To¡let
Type of OWTS
Percent Ground SlopeGround Conditions Depth to l'!t Ground water table
E underground Dispersal E Above Ground Dispersaltrench, Bed or Pit'flAbsorRtion
E Wastewater Pond E Sand FilterE Evapotranspiration
FinalDisposalby
E other
Will Effluent be discharged directly into waters of the State?
E Stream orCreek E Cisterntr we¡l
unity Water System Name
Spring
ffie;;;;
E Yes
Water Source & Type
Effluent
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mândatory 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 f-or 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.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided red information which is correct and accurate to the best of my knowledge.
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Property Owner Print and Sign Date I
FÞ lLV. oo)50þ8 tAL/ tl 'otr(
OTFICIAT USE ONIY
Special Conditions:'WA¡ww', þtwl inglrltrr{,on rûW(+ r.Awaù w¡ov t0 c.Q
Perk Fee:
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Total Fees:'lvv-Fees Paid:l7v-Permit Fee:l7r-
lssue Date:
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Balance Due:
ø
Buildine Permit
ßt^4F- 65TL
Septic Permit:
S?,gT-65+b
BUITDING/ PTANNING DIVISION:
Signed Approval
lZlt l"ow
Date