HomeMy WebLinkAboutApplicationGørfieúd Counly ONSITE WASTEWATER
TRE.ATMENT SYSTEM
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PERMIT APPLICATIONRECEMED
Community Dêvelopment Department
1oB 8th street, su¡te 4o1
Glenwood Springs, CO 8L601
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lation Alteration
WASTETYPE
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[f other Describe
PARTIES
Property0wner;Ca¡vin Læ Phone:
Mailing Address:255¡ Dexter Steel
Email Address:catü'rgfãüs@grÍsilæm
Contractor:Tonkâ Ëx€'¿ation
Mailing AddfeSS: 54t) Cafüs FÌaþ Roðd
Email Address:ross@hrnkaexwlim-com
Engineer:
! MailingAddress:
Phone:gtu-3a-!f;ffi5q
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Email Àddress:
PROJECT NÂME ANÐ LOCA¡OU
Job Address:oz30 cadË Fbas Rod, cãb€dsþ. ColqBdo 81623
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Assessolrs Parcel Nsmbe¡- 8$r1a0o0o3 Suh.UF Cde C¡eeksubdivÈÀbn Lot 3 Block_
Building or Service Type: Éi¡d€nriâ¡ #Bedrooms: 3 Garbage Disposal{Y1N}:-
Сstance to Nearest Cornmunity Sewer Systern:tdr rúb8
Was an effort made to connect to the Community Sewer System:m
Final Ðisposal Absorpt¡on trênch, Bed or Pit Ðispersal Ël AboveGround
E Wastei,raterPond Itll
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E Other rBrjlãcement of $€pliÊ la¡k øly
Water Source & Type El lâfell l" :er¡nc
E StreamorCreek E frstern
E Community lllfater System Name
[3Oüter -.. ,.,,.,., ,..... .
ToiletPriW:n
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PÎt
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E Aerat¡on Plar¡tEI SeptícTank
Recyclinç Potable Use E Reryding
Chernîcal Toilet
Vault E VaultP¡ivf f-ompostingowTsType
P€rcent Ground Slope ntaGround Condítions Depth to 1* Ground waterÞble 275 feet
Effluent Will Effluent be discharged directly into waters of the State?tr Yes El tr¡o
Appficant acknowledges that the completeness of the application is conditiona! lpgn such further
darrrla[clry and additîonal test and reports as may be required by the local health de,partment to be
made and-furnished by the applicant or by the local health department for purposed of the evaluation
of the application; anci the issuance of the permit is subject to such terms and conditions as dêemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewíthand required to be submitted by the applicant are or will be represented to be true and
correct to the belt 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 falsifiıation or misrepresentation may result in the denial of the
application or revocatíon of any permit granted based upon said application and legal action for perjury
as provided by law.
ËTRTTFICAÍION
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Property Owner Print and Sign
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I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information which ïs correct and to the best of my knowledge.
a
Date
Special Conditions:
Total Fees:
s?ð,00
Fees Paid:
ó?ı" oo
PermÍt Fee:s75.. oo PêrK Fêe;
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Balance Due:
þd,Ø
lssue Date:
xfts./to
Building Permit
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Septic PerlnE:
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BUII.D¡NG/ P¡.A¡I¡NING DIVISIOH:
Date