HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
T{ECEIVE[J Community Development Department
¡.rL r.' r ¡{ :i[111] 108 8th Street, Suite 401uL"(' * ..plenwood Springs, CO 81601
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TYPE OF CONSTRUCTION
New lnstallation E Alteration E ' Repair
WASTE TYPE
Æl Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Phone:
.¿4 GÐT
PhoneContractor:
Mailing Address:
Email Address:
/a.¿ lh l-D (LPhone:r (7/ut 2Ð4'*)-<)Engineer:
Mailing Address:
Email Address
PROJECT NAME AND TOCATION t
Was an effort made to connect to the Community Sewer System:^)a
fBedrooms:Building or Service Type:Q¡sìl¿n 0e
(? al
Assessor's Parcel Number:
Job Address:
Distance to Nearest Community Sewer System:
Garbage oisposal@ru)
lot / ô etocr
E vault E Vault Privy Compost¡ng ToiletuA SepticTank E Aeration Plant
E lncineration ToiletE Recycling tr P¡t Pr¡wE Recycling, Potable Use
E other
Type of OWTS
E Chemical Toilet
Percent Ground SlopeGround Conditions Depth to 1st Ground water table
E Underground Dispersal E Above Ground DispersalE Absorption trench, Bed or Pit
E Wastewater Pond E Sand FilterE Evapotransp¡rat¡on
Final Disposalby
E other
El Spring E Stream or Creek E CisternpjwetlWater Source & Type
Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditiona! gpgn such further
niandatory and additional test and reports as may be required by the local health de.partment to be
made and'furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and'the isiúance of the permit is subject to such terms and conditions as deemed
necessary to insuie compliance with rules and regulations made, information and.reports submitted
herewith'and required tó 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 a.pplie.d for herein. I
furiher understand that any falsifiãation 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 a
have
Property Print and Sign
I have read and understand the Notice and Certification above as well as
ls and accurate to the best of my knowledge.
r L
Date
OFFICIAL USE ONLY 6g
Spec¡al Cond¡t¡ons:
ooTotal Fees:s?5 '"3'ft; ooPerk Fee
FÐG
Perm¡t Fee:.ã'l< 6o
'7t-J'
Ba '"8¿)"',*Septic Permit:
3tr?"Ë |('aßr\"'i{ìqlnBuilding PermitNrn
BUILDING/ PLANNING DIVISION:
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Date