HomeMy WebLinkAboutApplicationGørfield County
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Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
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ONS¡TE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
TYPF OF CONSTRUCTION
El' lrlew lnstallation tr Alteration tr Repair
WASTE TYPE
Ef Dwelling EI Transient Use E Comm./lndustrial tr Non-Domestic
E other Describe
INVOTVED PARTIES aìt
Phone:
Email Address:
Property Owner:
Mailing Address:
Phone: ( )
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Contractor:
Mailing Address
Email Address
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Phone:
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Engineer:
Mailing Address
Email Address:
PROJECT NAME AND TOCATION
Was an effort made to connect to the Community Sewer System:¿ÂJe)
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A)Building or Service Type Q" ç tL,*I JJ
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#Bedrooms:
Distance to Nearest Community Sewer System
Assessor's Parcel Number
Job Address
Lot Block
Garbage Disposal(Y/N)
Ezseptic Tank E Aeration Plant E Vault E Vault Privy Composting Toilet
E Recycling E eit erivy E lncineration ToiletE Recycling, Potable Use
E other
Type of OWTS
E Chemical Toilet
Depth to 1't Ground water Percent Ground Slope #"6Ground Conditions
E Underground Dispersal E Above Ground DispersalE Absorption trench, Bed or Pit
E Wastewater Pond FSand FilterE Evapotranspiration
Final Disposal by
E other
EI stream or Creek lElcisterntr Well E Spring
E Community Water System Name
Water Source & Type
Will Effluent be discharged directly into waters of the state? E Yes É noEffluent
Applicant acknowledges that the completeness of the application is conditional upon such further
niandatory and additionaltest and reports as may be required bythe localhealth departmentto be
made and furnished by the applícant 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 for 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.
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Property Print and Sign Date
Special Conditions:
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Perk Fee:
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Total Fees8pq.o(>Fees Paid:VE?^*Permit Fee:
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Balance Due:
íd.ooBuilding Permit
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Septic Pärmit:gprt6.çn1-lssue Date
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BUILDING/ PLANNING DIVISION
Signed Approval Date
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