HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
REGE
Community Development Department
MÀy 0 tr 201$ 108 8th street, suite 401
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TYPE OF CONSTRUCTION
tr New lnstallation
WASTE TYPE
Dwelli
E Alteration
EI Transient Use tr Comm./lndustrial
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¡NVOLVED PARTIES
;Phone:3Propefi Owner:
Mailing Address:
Email Address:
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tr Non-Domestic
E Other Describe
Contractor:
Mailing Address:
Phone: (-)
H5'lr'* Cë '1UEmail Address:
Engineer:
Mailing Address:
Email Address:
Was an effort made to connect to the Community Sewer System: /'/e
Phone:
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flBedrooms: ? Garbage Disposal(Y/Nl Y7Ê
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Lot
-
Block
-
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PROJECT NAME AND TOCATION
Distance to Nearest Community Sewer System:
Building or Service TYPe:
Assesso¡'s Parcel Number:
Job Address:
E Vault E Vault trivyFsept¡cTank Aerat¡on Plant
E lncineration Toilet
Compost¡ng Toilet
Pit PrivyE RecyclingRecycling, Potable Use
E otherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to lst Ground water tableGround Conditions
E Above Ground DispersalÉ Absorption trench, Bed or Pit E Underground Dispersal
Sand FllterWastewater PondE Evapotranspiration
E other
FinalDisposalby
E CisternE Stream orCreekE springtr well
E CommunitY Water SYstem Name ¿l{
Water Source & TYPe
Will Effluent be discharged directly into waters E Yesof the State?Effluent
CERTIFICATION
Applicant acknowlcdges that tho completeness of the application is conclitinna! 1,p?n stlch ft¡rther
;i#àäå,.ü;;,i;aãñËilít"ìi.nà i"þorts ai mãy be req'uired by the local healthde.pa¡tment to be
l#äË];iï'niri:äiTiË";i,-piñ"iãi uv t " roéat healih department ror pu,rposed.of the evaluation
äitîãäóËlïðåï¡ı"; ã"dt-¡,ãiãiüå'iã" oitt'Ë p"irìtis.subjectto such terms ahd conditions as deemed
necessary to insure ..róián.ã *ith rules änã rêgulations made,.information and reports submitted
i;;;öñi,'.,ì,d ïãırirãi Ï5'Ëä'r-u-¡äüi"ã uv itre ap-plicant are or will b.e repres.entqd t9 bç true and
iãii"ifiäìr,ã ¡Lli oi rîrini*lãåsä;ni'bet¡ef ånd are designed to be relied on bv the.local
ããor-ñìiãnì ıfrrtalttr in'evaluatinfi the same for purposes oi issuing the. permit applied for herein. I
;liñLi'r;å;;;tä""äir.'äi ãÅv rrliìt¡Ëriión or misrepreientation maylesult in the denial of the
;i;ôii;åd,ilãir"uó.ãt¡on gÍ ant permit granted based upon said ápplication 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 the required information which is correct and accurate to the best of my knowledge'
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Property Owner Print and Sign Date
OFFICIAT USE ONLY ooIt
Special Conditions:
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Fees Paid:o6Total€Permit Fee:t
Balance Due:lssue Date:
Fee:o6
SepticBuilding Permit
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BUILDING/ PLANN¡NG DIVISION:
Dâte