HomeMy WebLinkAboutApplicationGurfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrsl
PERMIT APPLICATION
Community Development Department
108 8th Stree! Suite 401
Glenwood SPrings, CO 81601
l970l94s-82L2
www.garfield-countv.com
E other Describe
TYPE OF CONSTRUCflON
New lnstallation tr Alteration lr
WASTE TYPE
Dwelling E Transient Use tr Comm./lndustrial n Non-Domestic
ES
Property Owner:
Mailing Address:
Email Address:
Phone:
*
Engineer:
Mailing Address
Phone:
)4
Email Address:
PROJECT NAME AND
Job Address:
Assessor's Parcel Number:
Building or Service Type:fBedrooms
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System , NIN
_1 Garbage oisposal(Y$-
Lot Block
Mailing Address:
EmailAddress:
Phone: (-)L}
Contractor:
El other
Type of OWTS EI Vault PrivyE VaultSeptic Tank E Aeration Plant
E lncineration ToiletE tit PrivyE RecyclingE Recycling, Potable Use
Compostlng Toilet
EI ChemicalToilet
Percent Ground SlopeDepth to l't Ground water tableGround Conditions
E Above Ground DispersalE underground DispersalEl Absorption trench, Bed or Pit
E other
E Sand Filtertl Wastewater Pond
E Stream or Creek E CisternWellE Spring
E Evapotranspiration
E Community Water SYstem Name
FinalDisposalby
Water Source & TyPe
Will Effluent be discharged directly into waters EYes FNoof the State?Effluent
Applicant acknowledges that the completeness of the application is conditional upon such further
,rarrdarory arrd additio;;ii;:i';""älä[oiii ri '''iy be reciuirecl by the local healtl'r dcpartment to be
:ì1fl:ilå1Hffif:f,','ffflil*iil*i;:;,'i?ftl,:{ii:ü"""*il,"J"'J3:iïff;åfl:l:i"'i""xiltf "
necessary to insure .;rpl¡;;.äw¡tn rutes åni régulations made, information and reports submitted
herewith and requir"iiS'Ë';;b.iii¿A btih"-aRiticant are or will be repres.ented t.o be true and
äòi*.i'ibìr.,Ë oËi oiäVrlnìr,üt"¿ää;;à'uer¡ef ánd are designed to be relied on bv the local
ä;;r"r#;;i ıfhiàlir.t iÅ'evaiuatìn[Ú'e rare for purposes.oi issuing the.permit a,pplied for herein' I
i.'ür.,Lï ú"otirtr.a ir.räi ãrv trtiitiZ"iion or misrepre'sentation may result in the denial of the
application o," ,."uo..iio*n öÍ rnv p"rmit grantàd based upon said ápplication and legal action for perjury
as provided bY law'
flauaro
I hereby acknowledge that I have read and understand the Notice and certification above as well as
have provided the req uired information which is çorrect the best of mY knowledge.
Property Owner Print and Sign Date
fD l?-7.bot ll't+ß, s ?tl t6
OFTICIAT USE ONLY
I Conditions:
ivr,tub fr't'¡l in 0h .t.i'vrlF¡fÐtuIftw,/4Specia
Fees Paid:Total Fees:Perk Fee:
b.Permit
Balance Duelssue Date:
.'/ ,)r/lç
Permit:Building Permit
-tlz!?tøBUILDING/ PLANNING DIVISION:
Signed Approval Date