HomeMy WebLinkAboutApplicationGurfield CountY ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
lNlFld0 r-, "Community Development Department
^IN0O}
i'; : " l6gg,h Street,Suite401
iiitlil L i¡ .å"Flenwood Springs, co 81601
1970194s-82L2g3^l3Cgf www.earfield'countv.com
trtr AlterationNew lnstallation
WASTETYPE
Non-Domestictrtr Comm./lndustrialEl Transient Useli
E Other Describe
INVOLVED PARTIES
Email Address:
Phone:Property Owner:
Mailing Address:
Email Address:
Phone:
ê?zqMailing Address
Contractorl
Phone:Engineer:
Mailing Address:
Email Address:
PROJECT NAME AND LOCANON
Assessor's ParcelNumb er222/34¿Ðe/ /-!uA' ,/h¿ptb{a Lot
Was an effort made to connect to the Community Sewer System:
Job Address:
2-r-:1
3 Btock_
é-7")
Distance to Nearest Community Sewer System:
Building or Service TYPe:#Bedrooms: a' Garbage Disposal(Y/Nl tl'/
Composting ToilettrE Vault PrivyVaultE Aeration PlantSeptic Tank
El lncineration ToiletE eit erivyEI RecyclingRecycling, Potable Use
l/l/othe¡E Chemical Toilet
Type of OWTS
Percent Ground SloPe-Depth to l't Ground water tableGround Conditions
E Above Ground DisPersalE Underground DisPersaltrench, Bed or Pit
Sand FilterE Wastewater PondE Evapotransp¡ration
Other
Final Disposal by
E CisternE Stream or CreekE Spring
E Community Water SYstem Name
Water Source & TYPe
Will Effluent be discharged directly into waters E Yesof the State?Effluent
Appricant acknowredges that the compreteness of the apprication is conditional upon such further
nìandatorv and addit'iài;ii":i';;¡iiäı";i;'å;;ãyË,='çilrirgd bv the local health department to be
ilåä::.;åi;inirî"äïî'iî;.;ópiäÅiãi nv iñ.'rıð.T r.r"ãtiñ oepaitment ror pu.rposed.or the evaluation
of the application; ,nít-r.rã¡riüánðe of rhe Ë;¡miiË sJb¡ect to such terms and èondit¡ons as deemed
necessary to insure d;Ëii;;;äw¡ttr rutes fiå ;ääffitiã* .ãoe information and.reports submitted
herewith and requireäi|'åi'rïb;ìiiåä'bi/ih. åpil¡cant are or witl oe represented to be true and
correct to the ¡"rt otitî rin"oïl;äi;;;J 'dilãi;'iJ ã;e designed to be rèlied on bv the local
deoartmentof healthinevaluatinethesam'äiäióürpãrãioiissuingthe.permita,ppliedforherein' I
il.fiñ;î';å;;täiäîËäi ãnv trriir¡îrt¡on oi'mileþieientation mav-result in the denial of the
apptication or r"uo..i¡o*n äi.ñv p"rmit graniääi,ãrø upon said ápplication and legal action for perjury
as provided bY law.
I hereby acknowledge that
thehave
I have read and understand the Notice and Certification above as well as
information which is correct and accurate to the best of my knowledge'
Date
0
Owner Print and Sign
Special Conditions:
ooFees Paid:
óôÕ5
Due:ôolssue Date:
+ôJ e,lt Q
Perk Fee:
Septic Permit:
Permit Fee:í 6
Building Permit
¡â
BUITDING/ PLANNING DIVISION:
DateSigned
lo-