HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERM¡T APPLICATION
RECE Development Department
lo8 8'h street, Suite 401
JAN ? 2 Z0lÊrcn*ood springs, co 81601
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TYPE OF CONSTRUCTION
"E( ruew lnstallation tr Alteration tr Repair
WASTETYPE
Dwell E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Phone:
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4crriLa-t ,LD
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Email Address:
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Phone:
Mailing Address:
Contractor:
Phone: ( )f+o rn L0LuhbK-Engineer
Mailing Address
Email Address:
PROJEST NAME AND TOCATION
Was an effort made to connect to the Community Sewer System:
#Bedroomsr A Garbage Disposal(Y/N)1-
N0
Distance to Nearest Community Sewer System
E Lot Block
Building or Service Type il¡ur
Job Address
Assessor's Parcel Number:
p SepticTank E AeÌat¡on Plant E Vault E Vault Privy Compost¡ng To¡lettr
E Recycling, Potable Use E Recycling E Pit Privy E lncineration Toilet
Type of OWTS
E Chemical Toilet E other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
If Absorpt¡on trench, Bed or Pit lJ Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
FinalDisposalby
E Other
f, wett E Spring E Stream or Creek E c¡sternWater Source & Type
E Community Water System Name
Effluent W¡ll Effluent be discharged directly into waters of the State? E Yes s. tUo
I
Applicant acknowledges that the completeness of the application is conditional Vpgn such further
nia'ndatory and addiiional test and reþorts as may be required by the local health department to be
made andÎurnished by the applicant ôr by the local health department for purposed of the evaluation
of the application; and'the isiúance of thé permit is. su.bject to such terms and conditions as deemed
necéssa'ry to insuie compliance with rules ánd regulatiohs made, informat¡on and.reports submitted
herewith'and required tö be submitted by the -apþlicant are or will b.e represented to be true and
correct to the beit of mv knowledge and belief and are designed to be relied on by the local
department of health in'evaluatin[ 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.
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I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required on is correct and accurate to the best of my knowledge.
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Property Owner Print and S¡gn Date
Special Cond¡t¡ons:
oôFees Paid
Srq-laPerk Fee:
tl.5¿1.co eoTotal Fees:ítr3aää*
"'gä"bolssue Date:q Þqlßeqild¡ne È-erm¡t
tåaF-.5r&t
Septic Perm¡tr
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BUILDING/ PLANNING DIVISION
Signed Approval
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Date