HomeMy WebLinkAboutApplicationGurfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
RECEIVED 1oB 8th street, suite 401
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GARFIELD COUNTY www.sarfield-countv.com
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TYPE OF CONSTRUCTION
tr New lnstallation EK Alteration tr Repair
WASTE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
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Phone:
Email Address:
Property Owner:
Mailing Address:
Phone:Contractor:
Mailing Address:
EmailAddress:
Phone: (_)Engineer:
Mailing Address
Email Address:
Was an effort made to connect to the Community Sewer System:
/-*y C. ve , {S;ce
N)r\
Building or Service Type:#Bedrooms: Garbage Disposal(Y/N)-
Distance to Nearest Community Sewer System:
Assessor's Parcel Number: Sub.
PROJECT NAME AND
Job Address:
Lot _ Block _
E Vault E Vault Privy ! CemnostingToilet.l[ SepticTank E Aeration Plant
E Recycling, Potable Use El Recycling E P¡t Pfiw E lncineration Toilet
Type of OWTS
E chemical Toilet E other
Percent Ground SlopeGround Conditions Depth to lsr Ground water table
F. Absorptíon trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
Final Disposalby
E other
E Stream or Creek E císternE Well E SpringWater Source & Type
E Community Water System Name
WillEffluentbedischargeddirectlyintowatersofthestate? E Yes E NoEffluent
: CERTIF ICATION
Property Owner Pri and Sign
Applicant acknowledges that the completeness of the application is conditional upon such further
nìándatory and additional test and reports as may be required by the local health department to be
made and'furnished by the applicant or by the loeal 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
necessaiy 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 belt of my knowledge and belief and are designed to be relied on by the local
department of health in-evaluatinf the same for purposes of issuing the. permit a.pplied for herein. I
fuither understand that any falsifióation 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 provi the required which is correct and accurate to the best of my knowledge.
Date
I
OFFICIAL USE ONIY oc)gJ*
Special Conditions:a
Fees Paid:
9?s-oôPerk Fee:Total Fees:9?5.0oPerm¡t Fee:
6 75.oo
lssue Date:
a) t,/to Balance Due:dd.æSeptic Permit:
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Building Permit
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BUILDING/ PLANNING DIVISION
Signed Approval
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Date