HomeMy WebLinkAboutApplicationGarfield County ONS¡TE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
TYPTOF CONSTRUCTION
E tr¡ew lnstallation tr Alteration tr Repair
wAsTE TYPE
[, Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Phone
¿.Cò
OWNVK Phone: ( )Contractor:
Mailing Address:
Email Address:
Phone: ( )Engineer:
Mailing Address:
Email Address:
PROJECÍ NAME AND IOCATION
Was an effort made to connect to the Community Sewer System:
Garbage Disposal(Y/N)-
rct al Block
-
Job Address:
Distance to Nearest Commun¡ty Sewer System:
Assessor's Parcel Number:Sub.
Buitding or service tvp", RI$ t (L! h,,îrt
E Vault E Vault Privy ! Comnosting ToiletEf Septic Tank E Aeration Plant
E Recycling, Potable Use E Recycling E P¡t Pr¡vy E lncinerationTo¡let
E Chemical Toilet E other
Type of OWTS
Depth to 1st Ground water table Percent Ground SlopeGround Conditions
E Underground Dispersal E Above Ground DispersalEyAbsorption trench, Bed or P¡t
E Wastewater Pond E Sand FilterE Evapotransp¡rat¡on
EJlthet
FinalDisposalby
\É well E Spring E Stream or Creek E cistern
E Community Water System Name
Water Source & Type
Will Effluent be discharged directly into waters of the State? E Yes F "oEffluent
N
Applicant acknowledges that the completeness of the application is conditiona! Vpgn such further
niandatory and additional test and reports as may be required by the local health depa-rtment 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
necessa'4i 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 the required information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
Ft)tL7.n) 4 L(q
OFFICIAL USE ONLY
Special Conditions:
Total Fees:173-Fees paid:
I X_Perm¡t Fee:[>3-PCTKFCC:
EN6
lssue Date:
ôø/tz/ tq
Balance Due:
Í(7f-*Building Permit
BUI-5Tb7 'TëËî'YWg
BUITDING/ PLANNING DIVISION:
Signed Approval
20t4pÁj,ùW
Date