HomeMy WebLinkAboutApplicationGarfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
rl rr ¿r å 108 8th Street, Suite ¡101
JUL u S êfHfi"ood sprinss, co 81601
gî[,i,iFiß'??"'"il#,ll"',Í.'.iÍ"'i..","
TYPE OF CONSTRUCTION
tr New lnstallation
TYPË
Development Department
E Transient Use
Alteration
tr com ndustrial
Repair
Dwelli
INVOTVED PARTIES
Non-Domestictr
E other Describe
Õ
oEmail Address:
Property Owner:
Mailing Address:
Phone:Contractor:
Mailing Address:
Email Address:
Engineer:
Mailing Address:
Email Address:
Was an effort made to connect to the Community Sewer System:
I
Lot
1^ö
Phone :l
/(
#Bedrooms:
Block _
3 earbage Disposal(Y/N)-
rSI14Distance to Nearest Community Sewer System
Building or Service TYPe
Assessor's Parcel Number: Sub'
PROJECÍ NAME AND
Job Address
E Vault Privy l-l Composting ToiletE¡ vaultE Aerat¡on Plantp Septic Tank
El Pit lrirry E lncineration ToiletE RecyclingE Recycling, Potable Use
E OtherE Chemical Toilet
Type of OWTS
Percent Ground SlopeDepth to lst Ground water tableGround Conditions
E Above Ground Dispersal[J Underground DispersalE Absorpt¡on trench, Bed or Pit
E Sand FilterE Wastewater PondE Evapotranspiration
t
E other
FinalDisposal by
El CisternE Stream or CreekE Springll well
E CommunitY Water System Name
Water Source & TYPe
Will Effluent be discharged d¡rectly into waters E Yes E ¡¡oof the state?Effluent
f
l CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional Ypgn such further
.ri"J;åäå;;;d åäã''tñ;iË:l;lràöorts as may be rei{uired by the local health de.partment to be
ffiää;å'f;;ìtî;ä Ët ih" ãp-pli.ãnf irr by the loóal he.alth department for pu,rposed.of the evaluation
ääñËä'óËlìäåi¡ãli; ãrdtïãiiiüá"ð" ôithã permit is.su.bject to such terms ahd conditions as deemed
necessary to insure ."róliáitä *itt ruìês ånd regulatioîs made,.information and.reports submitted
üãià,i,"¡iir'"ri";";;ìr;ãïã ¡Ë zuumìtteà ¡y *re apþlicant are or will b.e repres.ented to be true and
;;;*.ii;iË'¡"T of rîmñtedge and bel¡ef änd are designed to be relied on by the.local
ã;;rt"ìé,ii ıftréanrr ¡n'evaiuatiñãthe same for purposes oi issuing the.permit a.pplied for herein. I
i;{h;;';å;;;täiält'äi ãñv tãiiit¡i"tion or misrepre'sentation may result in the denial of the
;;òiñ;'r;óiiðuıcát¡on äf rnv pérrit granted based upon said application and legal action for perjury
as provided bY law.
I hereby
have provided
Property Owner and Sign
that I have read and understand the Notice and Certification above as well as
uired information which is correct and accurate to the best of my knowledge.
7: ?*/ /
Date
OFFICIAL USE ONL Ø
Special Conditions:
Fees Paid:o0'0oTotal Fees:IPerk Fee:ooPermit Fee:ûs
OABaSeptic Permit:
S
Building Permit
BUILDING/ PLANNING D