HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
munity Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
l970l945-8212
www.ga rfield-countv.com
TYPE OF CONSTRUCTION
New lnstallation
WASTE TYPE
Dwellin E Transient Use tr Non-Domestic
INVOLVED PARTIES
Property Owner:
Mailing Address:
Email Address:
Phone:
Mailing Address:
Contractor:Phone:
Email Address +hN6¿ßi{ btÅ'l ccàl . oa }4
Engineer:Phone:
Mailing Address:
Email Address:
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PROJECT NAME AND
Job Address:
Assessor's Parcel Num
Building or Service Type #Bedrooms:3 Y blV
Distance to Nearest Commun¡ty Sewer System:?r
Was an effort made to connect to the Commun¡ty Sewer System Nn
Final Disposal by
Water Source & Type
Block
Disposal(Y
Effluent
rtrRE Alteration
tl Comm./lndustrial
E Other Describe
)L septic Tank E Aeration Plant E vault E vault Privy n Composting Toilet
E eit Privy E lncineration To¡letE Recycling, Potable Use E Recycling
E Chemical Toilet E Other
Type of OWTS
Percent Ground Slope ItDepthto 1st Ground water table S- ãt4 tGround Conditions
E Underground Dispersal E Above Ground DispersalE Absorpt¡on trench, Bed or Pit
E Wastewater Pond E Sand Filterf. evapotranspiration
E other
Iwett E Spring E Stream or Creek E Cistern
E Community Water System Name -7Ø WbÀ UY (zl\A''\J
Will Effluent be discharged directly into waters of the State? E Yes F *o
CERTITICATION :.--.,--..
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of health in evaluating the same for purposes of issuing the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application 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 red info which is correct and accurate to the best of my knowledge.
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Special Conditions:
Total Fees:
123
Fees Paid:/zz,"r^trr..r/ J 3 PerkFee:
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Balance Due:
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Building Permit
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Sept¡c Permit:
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BUILDING/ PLANNING DIVISION:
DateSigned
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