HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPL¡CATION
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Ufll "¿ ? '¿ü1$ Glenwood Sprinss, co 81601
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TPE OF CONST.RUCTION
tr New lnstallation tr Alteration tr Repair
WASÍËTYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
El other Describe
INVOLVEDPARÏIES
Propefi OWnef: Jer€my Johnson Phone:leTo 1945-6857
Mailing Address:252 Coryell Ridge Rd. Glenwood Springs, CO 81601
EmailAddress:iۧmy@cattlscreokmillwork.com
ContraGtor:OWNERS REP.. Todd M6€ann pþs¡g¡ (szo | 98 t-stJ4z
Mailing AddfeSS: SameåsAbova
EmailAddress:todd@cattlecrækmillwork.com
Engineer:Dale Kaup Phone: (e7o ) 945-9tt13
MailingAddress:1129 GEnd Avê Glonwoód Springs, CO 81601
Emâ¡l AddfgSS: dale@ksupsnginssring.com
PROIECT NAME AND LOCANOiI
Job Address:252 Coryell Rldg6 Rd (252 County Roãd 167) Glenwood Springs, CO 81601
Assessorr's Parcel Number: Sub.Township 7 South [s[ temozt þ1q3ft
BuildingorServiceType:-#Bedrooms:-GarbageDisposal(Y/N)N
Distance to Nearest Commun¡ty Sewer System:??
Was an effort made to connect to the Community Sewer System:NO
Type of OWTS El SepticTank E Aerat¡on Plant E Vault E vault Prirry ñ CompostlngToilet
E Recycling, Potable Use El Recydlng E P¡t Pr¡vy E lnclneration Tollet
E chem¡cal To¡let E other
Ground Conditions Depth to 13t Ground water table Percent Ground Slope
FinalDisposalby [1 Absorption trench, Bed or Pit E Underground Dispersal E AboveGround Dispersal
[I Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type El Well El Spring E stream or Creek El cistern
E Community Water System Name
Effluent Will Effluent be dlscharged directly into waters of the State? f,l Yes El No
Applicant acknowledges that the completeness of the application is conditional qpgn such further
nia'ndatory and additional test and reþorts 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 isiuance 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 be3t 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 falsifiıation or misrepresentat¡on 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 Notlce 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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Print and Sign Date
Special Condltions:f
Total Fees:975" oÒ s +5. ooFees Paid:Permit Fee:ð7s.oo Perk Fee:tslrf-
lssue Date:
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Due:ooBalance
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Building Permlt
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Septic Permlt:
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BUITDING/ PTANNING DIVISION:
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