HomeMy WebLinkAboutApplicationGø.rfield Counly
REC E lV E D com m u n iwrn*ever o n11l"o;f; *nt
"
nt
AU6 ? 7 2018 Glenwood sprinss, co 81601
rnnft '*l,gp..ò"llñr,*-"Ï1,?"iü:,"1i,,*
rtrRetr Alteratíonlnstallatíon
nd ustria Itr tr Non-DomesticE Transient UseE Dwell
Other Describe
.'íNVOLVED. PARTIfS
Prop€rty Owner:
Mailing Address:
Email Address:
Conlractor:Phonel I
Mailing Address
Ernail Address¡
Engineer:
Mailing Address:
Email Address:
Job Address:
.Assessor's Parcel Number:5ub Lot Block
tÁ/Building or Service roorns¡Garbage r{Y/N
Distance to Nearest Community S€wer System:
Was an effort made to connect to the Community Sewer System:
Type of OWTS E Septlc Tank E Ae¡atlon Ptant E Vault E Vault Privy fl Compostlng Toilet
E Recycling, Potable Use Ú Recycflng E Pit Privy El lncineration Tollet
E Chemical Toilet El other
Ground Conditions Depth to l,t Ground water table Percent Ground slone l,€59 'Íþk¿r f;
FinalDisposal by D Absoþtion trench, Bed or Plt EI Underground Dlspersal t Above Ground Dispersal
E Fvapot¡anspiration E Wastewater Psnd E Sand Filter
E other
Water Source & TyPe Kwell E sFing fl Stream or cre€k E cistern
Community Water SYstem Nañe
Effluent Will Ëffluent be dlscharged dlrectly lnto waters of the State? E Yes trl No
Apnlicant acknowiedges that thr: conrpletene.ss r¡f the application is condltional gRon suctt further
;tiri'ü;i;rä;ilå¡ãir"Í,;#itàst and reirorts as may be required by the local health depa-ftment to be
;;;;;îd'füinirîäO nV ti e applicant br by the loåal health department for pu.rposed.of the evaittation
äiìiã äóËt¡äåiì;;; ;rd tüã¡iíuãncó of t¡ei permit is subject to such terms a'nd condltÍons as deemed
nccessaryto ¡nsure comót¡"ncJwith rules ånd regulations trtacle, lnfornration and repofts subtltitted
i-';;"-;i;h'."d ïããulréãìð Uã sunm¡tteU by the ap-plicant are or will be represented to bc true and
correct to the beit of my knowledge and belief and are designed to be relied on by the, local
dä;rtilã;i ói¡rìanf' tn'evaluatinã the same for purposes of issuing the. permit a.pplied for herein. I
further understand that any falsifiiatlon or misrepresentation may result ¡n the denial ot tne
àîiii.itiår ãirãuıcation ôf anV permit granted based upon said application and legal action for perjury
as provided by law.
I hereby
Property Owner Print and Sign
that I have read and understand the Notice and Certification above as well as
which is corrÊct and accurate to the best of my knowledge.
f^te-16
Date
Special Conditions:
t"ut o"'otú
f
Total Fees
.()6Perk Fee:
EnPermit Fee:+tß.oo
DUe:+lssue Dale:
I
Septic Permlì:BuildinB Permit
BUTLDING/ PLANNI NG DIVIS¡ON:
Signed Apptoval
toløløø
Date