HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERM¡T APPLICATION
APR 1 B ?OI7 Community Development Department
108 8th Street, Suite ¡101
Glenwood Springs, CO 81601
(9701 94s-8212
www.garfield-counW.com
E AlterationNew lnstallation
WPE OF CONSTRUCTION
WASTE WPE tr Comm./lndustrial tr Non-DomesticE Transient UsefEþDwelling
E Other Describe
IÍ{VOIVED PARNES
propérty Ownerz -f løOntY ila /Z'ar?fþÐ-Y1 Tru Phone:
Mailing Address;ZG).< øABÐ f lLb e Dn rE a.ô k)bz1
Email Address:(.
Contractor:Phone: f )
MaillngAddress:
Email Address:
Engineer:Phone: lî'N t 3e7 5:zS-7
MailingAddress:-? 3 'Fooe-ø rt€Ëe þø Ðt+I,F c-ø .9 I b 2,2
Email Address:
PROJECT NAME AND IOCATION
Job Address:
Assessoy's Parcel NumbeÊ l-31-,W,ØoqQ.sub.
-
Lot Block
Bulldlng or Serv¡ce Type:
-
#Bedrooms:Garùage Disposal
-
Distance t,
Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:/./ b
Type of OWTS EFSeptlcTank El Aeratlon Plant E vauh E VauhPrlw tr compostlngTollet
E Recyclln& Potable Use tl Recycllng E¡ Plt Prlrry E lnc¡neraüon Tollet
El Chemical Tollet El other
Ground Conditions Depth to 11 Ground watertable Percent G¡ound Slope
Flnal Disposal by E Absorptbn trench, Bed or Plt E Underground Dlspersal E AbovecroundDl¡persal
E Ernpotranspiraüon E westewater Fond E Sand Rlter
E orher
Water Source & Type oE well E Spring E StræmorCreek E clstern
E Commun¡tywatersystem flame
Effluent lMll Eff,uent be dlsdrarycd dlt€cdy ¡nto wtte6 oú the State?E Yes
CERT!FICATION
Applicant acknowledges that the completeness of the application is conditiona! ypgn such further
niin¿atory and additi-onal test and reþorts as qay be required by the local health dê;nartment to be
mã¿e ån¿ furnished by the applicant br by the loóal healih department for pu.rposed-of the evaluation
of ltrã app¡¡cation; and the ¡siúance of thi permit ¡s. subject to such-terms and conditions as deemed
necessarv to insuie compliance with rules ånd regulatiohs made, information and reports submitted
treiew¡it¡'an¿ required tö be submitted by the -apþlicant are or will be represented to be true and
correct to the beit 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 perm¡t applied f-or herein' I
further understand that any falsifiıation or misrepresentat¡on may result in the denial of the
aôpiiðation ırrevocation oi any permit granted b'ased upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and underctand the Not¡ce and Certification above as well as
have provlded the requlred information which is correct and accurate to the best of my knowledge.
1't8-t?
Property Owner Pr¡nt and S¡gn Date
PÞ.lLÐ, cc,I t?
OFFICIAL USE ONIY
Speclal Condltl,ons:
Total Fees:tb Fees Pald:l2vPerk Fee:
eN6.," nr."rrL?
Balance Due:
þ
lssue Dete:
.t3.7)"1+Bulld¡ns Pemlt
BtÆ.- t+bßtl
sêDt¡c Pemlt:
36vr- t+IoK
çlnl%nBUTTDTNG/ PI-AI{NING DIVISION:
Signed Approval tÞte