HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATIOI\.I
Community Development Department
108 8ú Streetr su¡te 401
Glernryood Springs, CO 81601
l970.l94s-821,2
www.çarfr eW -cgrtnÍt, com
CONSTRUCTION
lnstallation
J WASTE TYPE
Alteration tr Repair I
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sient Use tr Comm./lndustrial tr Non-Domestic--t-
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I rrvorvgo PAßTrEs
Property orrrnãrt
MailingAddress:
Email Address:
Contractor:
Mailing Address:
Phone:
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Email Address:C.ß^¡çraLCoto çfe-4tlfs5 ''*er
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Engineer:Ç
Mailing Address:3-r FauÈ 'rr{+r.e-uÞe-rvç- RÞ,. C^.
Email Address:(z.L.f r o(
PROJECT ITAME AND IOCANOil
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Job Address:- 1lô 1".\frltt;,¿rñ (4,JÉ c}
Assessor's parcet r{umb "r=2314 *63 f1o"#u,K-f . Png-gøRv l- r"t T Btock
-BuitdingorServiceType: RE9\DçJùåE- frBedrooms: I oe? earbageDisposal(Y/l{LL
D¡stance to Nearest Community Sewer System;z v\{LF,(
t¡vasan effortmadetoconnecttotheGommun¡tysflrer System: l'T l4 bì/rT. F2çôiTel--E-
Final Disposal by åbsorption trencfi, Eed or Pit E undergrotrnd Dirpersal ¡ E Above Grornd D'lspersal
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E Erapotranspiration E Wa¡tevaærPond E Sand Fiher
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ri otter
Water Source & Type Well E Spring [] streamorCreek E cistern
E CornmuniÇ Water System lueme
Vault
itr"
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Type of OWTS I
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:tr Recyding
El Aeratlon Plant iSepticTank
E Recycling Potable Use
E Chemical Toilct E other
tr Vault ToiletPriv.¡Compost¡ng
p¡r tr ToiletlncincrationPriW
P€rcent Ground SlopeDeptt to ls Groünd water tablc
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Ground Conditions
Effluent Will Effluent be disctrarged dircctly into water¡ of the State?E Ye¡f{o
cEanFrcAnofl
Aonlicant acknowledses that the compteteness of the application is conditional upon such further
;;i"#äiö;il1åäã¡tiıñiitãrl-à reþorts a.s qay þ9 required by the localhealthde.partment to be
lfãããã"¿'tùrnished Olttt" ãópìicant br by the loéal healih department for pu.rposed of the evaluation
äi thã ãpplicat¡on; rndt-ltã¡ti,Lnià oi rhd permir is. subject tosuch terms and conditions as deemed
ã"iãisãiiió ¡niuie.ornóialce rith rutes ånd regulations made,.j¡jormatjolan_d reports submitted
ftãiã*¡tlt'"nd requ¡rJ fö Oe iubm¡tted by the ¡FÞl¡cant are or will b-e rep.resentqd tg be true and
äıä"alo inè Uãit ot Ñ Ènow¡e¿ge andbelief ánd are designed to be relied on by the local
ããóãñitiãnt ıilrãamin'eJaiuat¡nã the same for purposes oÍ issuing the.permit a.pRlied for herein' I
i;riËñd6¡sü;Aihai ãny fatsification or misreþrebentation m.ay result.in the denial of the
applièation ot tuuo."i¡o I oí anv ietmit granted based upon said ápplication and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and under¡tand the Nstice and î-erlffrcetion abone as uell as
have provided the reguired ryhich ís correct and acsurate to the best of my knowledgc.
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Property owner Print and Sign
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Date
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OFFICIATUSE ONTY
Special f.onditions:
Fees Paid:
,Ø
Total Fees:
5.¿rb
Perk Fee:Permit Fee:
€ tl,o¡
Balance Due:l55ue Date:ss53Building Permit
BUrlDrr{6/ Pl¡Nf{lNG DIVlSlOñl:
DateSigned