HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
.lRECElVEBnwood Springs, CO 8X601
FEB o s 2o&..9-:lJúffi1ä,"*
GARFIELD COUNTY
WASTE TYPE
tr Dwel El Transient Use ndustrial
tr
tr Non-Dornestic
tr Alterationlnstallation
E other Describe
INVOTVED PARNES
Phone:Property Owner:
Mailing Address:5 t4-)
EmailAddress:
Phone:Contrâctor:
Mailing Address:
Email Address:
Engineer: Phone:
Mailing Address:
Email Address:
I(
PROJECT NAME AND TOCATION I
^
Distance to Nearest Community Sewer System:
Was an effort made to connect to the €ommunity Sewer System:No
5
Building or Service Type:fr Bedrooms:
-
Garbage Disposal(Y/Nl-
Assessoy's Parcel Number:
Job Address:
Lot Block
E vault Prirry tr CompostingToiletE SepticTank Aeration Plant Vault
E Recycling E P¡t Pr¡w [f lncineration ToiletE Recycling, Potable Use
E ChemicalToilet f,l other
Type of OWTS
Percent Ground SlopeGround Conditions Depth to 1s Ground watertable
E Absorption trench, Bed or Pit E Underground Dispersal E Above Ground Dlspersal
E Sand FilterE Evapotranspiration E Wastewater PondI
FinalDisposal by
!.ottrer
E Spring E streamorCreek E c¡sternE wel¡
E Community Watêr System Nðme
rce $ Type
N/A
Water Sou
Effluent WillEffluentbedischargeddirectlyintowatersofthestate? E Yes Fr"
iCERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and addii'ronal test and reþorts as may be required by the local health de.partment to be
made andÎurnished bv the applicant ôr by the local health department for purposed of the evaluation
of il'," ãpplication; and the isiúance of thé permit is. subject to such terms and conditions as deemed
necessa'ry to insuie compliance wíth rules ånd regulations made, information and.reports submitted
he.ew¡th'and required tò be submitted by the apþlicant are or will be represented to be true and
correct to the beit of mv knowledge and belief and are designed to be relied on by the local
department of health in'evaluatinf the same for purposes of issuing the.permit apRlied for herein. I
further understand that any falsifiıation 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 acknowledge that I have read and understand the Not¡ce and Cert¡f¡cation above as well as
have provided the requ¡red which and accurate to the best of my knowledge
Print and Sign Date
oFFrcrAtuscoNtY ftrTd 4 AilA /.tÞ+SSS $t?3oo
Special conditions:
'"ö'/5's. *Total Fees:6tz3 ooPerm¡t Fee:
4 rez.6a
Perk Fee:$lÀ
lssue Date:q.t\.\A '#5.'aoSeptic Permit:
strfr-¡5tôôBuilding Permit
€l-0n-irôqq
zlnløø
Date
BUITD¡NG/ PTANNING DIVISION:
Signed Approval