HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
lp7ols45-8212
www.ga rfield-countv.com
TYPE OF CONSTRUCTION
F New lnstallation tr Alteration tr Repair
WASTE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
INVOIVED PARTIES
Property Owner:
Mailing Address:
tlrl È¿s fô P4Þ4.tf\Nusz Phone: (q ryP)
Ðt L6l
.7 Lt F-Zo ll
'i6 t-/t-l þ/t¿Y Èz- /;LL)s eo
Email Address:? tùt tA Nu cz' t \Z ê, a nt ßl L t c
Contractor:<nø¡i ñ .ø Fn Phone: { )
Mailing Address:
Email Address:
Engineer: 4LL SàßUteÊ s:eq'r/c c>hrLL+ ASTBeI¿"Phone
Mailing Address:3 3F €ttltL /.//1È11'/-Ê Ð þ-¿U Ë R ô
Email Address:C'¡an l^n, ôSi-8 e-aø êà (î .ru^atr , Côþ7
^
PROJECÍ NAME AND IOCATION
Job Address 3L¿/q tlWV .+z- c ¿ùs cÒ 8t éo /
Assessor's Parcel Number: "2 t81zrys ¡h z-tot ?^ Block
-Building or service Tvpet 5 üvê ¿E FA4 ¡14+ nLU fBedrooms: 4 earbage Disposal(Y/N) '/
Distance to Nearest Community Sewer System:ft/Ê-tT Ðt Ll /,,'Y A L
Was an effort made to connect to the Community Sewer System û/0
Type of OWTS E SepticTank E Aeration Plant E vault E vault Privy I ComnostingToilet
E Recycling, Potab¡e Use E Recycling E P¡t Privy E lncineration Toilet
E Chemical Toilet E other
Ground Conditions Depth to lst Ground water table Percent Ground Slope
Final Disposal by E Absorption trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration tl wastewater Pond E Sand Filter
E Other
Water Source & Type E well E Spring E Stream or Creek E Cistern
E Community Water System Name
Effluent WillEffluentbedischargeddirectlyintowatersofthestate? E Yes I tt¡o
CËRTIFICATION
Applicant acknowledges that the completeness of the application is conditiona! r¡pgn such further
"ün¿ãtorv
and addiiioñittàst and reþorts as may be required by the local health de.partment to be
rããðãî¿'frrnist àU by the applicant ôr by the loóal health department for pu.rposed.of the evaluation
ääÏã äóplìðåtiı,ì; ãld t-t ã ¡iiüán.e of thé permit is. su.bject to such terms and conditions as deemed
necessa'rv to insure corpiiance with rules ànd regulatioîs made, information and reports submitted
f'ãiã*Ït'ri6 iãqrirãO iö be submitted by the apþlicant are or will b.e rep.resentqd t9 bç true and
.ãir".fioìt'ó ¡ãü ol mv knowledge and belief ãnd are designed to be relied on by the.local
ããórrtnìã'ìt ıf f'eãnt' in'evaluatinf the same for purposes oi issuing the. permit applie.d for herein. I
irriñuì ,ñ¿èistáñO that any falsif'ñation or misreþresentat¡on may result in the denial of the
àîòiiðátî"ñóireuó.àtion of any permit granted based upon said ápplication and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information ch is correct and accurate to the best of my knowledge.
HR)5 ¡-g
Property Owner Pr¡nt and S¡gn Date
OFF¡CIAL USE ONLY
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Special Conditions:
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Fees Paid:
lza,ooTotal
129.0o
Perk Fee:
çNO.
Fee
t2.
Perm
OD
Balance Due:lssue Date:Permit:6l.zzBuilding Permit
LM
BUILDING/ PLANNING DIVISION:
Signed Approval Dete
oltqlaorc
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