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EmailAddress:
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Phone:
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Contractor:
Mailing Address:
EmailAddress:
ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Gørfield CountY
rtrtrAlterationnstallationNew
Non-DomestictrCommtrEl Tra nsient Useil¡
DepeÉment
1\Suite 401
\\$(e7ol94s-82L2
Springs, CO 81601
www.ga rfield-counW'com
ElOther Describe
Phone:
Engineer:
Mailing Address:
EmailAddress:
Job Address:
Assessol's Parcel Number:7^
o5
Building or Service TYPe:
Distance to Nearest Community Sewer System:
Was an effort made to connect to CommunitY Sewer SYstem :
ilBedrooms:
9
tr VaultPrlYY
Percent Ground SloPewater tableDepth to 1s GroundGround Conditions
E Stream or CreekWell
[1 CommunftY Water System Name
Water Source & TYPe
Clstern
Aopricant acknowredges that the compreteness of the appricatìon is conditionar upon such further
niindatorv and additiãnar rest and reports'å:Ëi Ë'ätiirãà uv ttrãlocal health department to be
flä"'?rflil::lrH*i.,li';ln1l.:iüi¡i;::,'t;'¡i1,ru[{l:lri*:lr+1ru'ffif,,:":x1"0:'Ji'1T"
necessary to insure .JrËì'iåi..-*itï ,"jF ffå';ääYJåü".rrTgg."',inrormãtion and.reports submitted
herewith and requireäïå'üî';b'rìiË¡ ËiiË apîr¡cant are or ui¡il ¡e represented tó be true and
correct to the u"rt otir,îË,iorüËäääätåiËüriüä oËsiúeã to be réried on bv the
'ocaläËË.t ti"ã"i'ãinllåñù, i"'evair,rqt!1ãt¡e sarñäiä;üö'ä; if ¡';n'e,Éu"rfi,lfrtå88,.*,i1"r1.,!erein' I
i;{ Ëi'ñå;;tä-nä Ir, ät ã ni iâr s ¡ricati o n o r m i s re p rese ntat i o n n
aoorication or rcvocation of any permit er.ntåî bãtãï uþon saidãpprication and legal action for perjury
ai þrovided bY law.
I hereby acknowledge that I have read and understand the Notice and certification above as well as
have provided the required information which is conect and accurateto the best of my knowledge'
Property and Sign
Þ ÇUz ñ> LLt s1t4 rC
Special Conditions:
FeesPald:
?tTÒ -rstetFees'yn "-Perk Fee:Fee:
2 Balance Due:Date:lssue b/sltPermit:-q1/)
Bullding Permit
BUITDING/ PI¡NNING DIVISION :a3rÐ],3
Date