HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
New lnstallation , E Alteration tr Repair
WASTE WPE
Transient Use tr Comm./lndustrial E Non-Domestic
El Other Describe
; INVOLVED PARTIES
Property Owner:
Mailing Address:
r Email Address:
Contractor:Phone:
Mailing Address:
EmailAddress:
Phone:
tl
Phone: I )
b.
#Bedrooms:
Sewer System:7,(o "¡-tt-.¿3
the Commun¡ty Sewer System irt
E Above Ground Dlspersal
E sand Fllter
Sprlng E Stream or Creek i ,É cistern
Weter System Neme
34N
Engineer:
Mailing Address:
Email Address:
PROJECÍ NAME AND
' Job Address:
Assessor's
Building or
Distance to
Was an effort
FinalDisposal
Water Source
In
1e
tt
tto
Type:
rNumber:
t rtlc Tank E Aeration Plant E Vault E Vault Privy
I rycling, Potable Use E Recycllng P¡t Prlvy
Type of OWTS
l rmical Toilet
Composting Tollet
lncineration Toilet
E other
n
Ground Condit ons th to lst Ground water table /1)/ft Percent Ground Slope
I rb iorption trench, Bed or Plt E Underground Dispersal
I
I
v¡
rü
E Wasteurater Pond
9
l
: Effluent
Type
be discharged directly lnto waters ofthe State? tr Yes v No
EERTIFI
Applicant a
mandatory an
made and
of the applicat
necessary to i
herewith and
correct to the
re
of
department health in
further unde nd that
application or
as provided law.
I hereby ac
have provided the
Own
?b
.¡
o
l¡
n
y permit granted based upon said application and legal action for perjury
have read and understand the Notice and Certification above as well as
which is correct and accurate to the best of my knowledge
P
)tç.TtrT cI
a
Print d ;¡1
otFlclAr tY
Speclal
Permit Fee:
lc'2?
P lrl Fr l5o-Total Fees:?-+v-Fees Paid:?-rr-
clBuilding Permit
vlrtE- cfr'+4
s
tT- 6b++'erm¡t:lssue Date;
! .rt+.\A Batance o".,
ø
)N )BUTLDTNG/Dtvtst
Signed
I
I4øto
Date