HomeMy WebLinkAboutApplicationGørfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
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Development Depa rtment
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970194s-8212
www.garfield-countv.com
rtrtr AlterationE New lnstallation
WASTE TYPE tl Non-Domestictl comm ndustrialE Transient UseE Dwelli
E Other Describe
Phone:Property Owner:
Mailing Address
Email Address:
Po. ßox 9¿.r lVeu (r't*le
Phone: (9ro \ 9t
-P,/./¿ Þ17
Contractor:
Mailing Address
Email Address:
Engineer:
Email Address:
Assessor'sParcel Number: 2lî7t9?olooÐsun' CfæÞ¡tde e¡ùahr øt ? Block è
Building or service lvp., Re¡rðenlìa 2 fBedrooms: t'l Garbage Disposal(Y/Nl Y
Distance to Nearest Community Sewer Systemi
WasaneffortmadetoconnecttotheCommunitySewersystem:
Phone: ( )
AND LOCATION
Mailing Address
Job Address:
PROJECT
I Comnosting ToiletE vault E vault Pr¡wE SepticTank E Aeration Plant
E Rit lrivy El lncineration ToiletEI RecyclingE Recycling, Potable Use
tl otherEl Chemícal Toilet
Type of OWTS
Percent Ground SlopeDepth to 1st Ground water table uttl¿Ground Conditions
E Above Ground DispersalE Underground DispersalE Absorption trench, Bed or Pit
E sand F¡lterEl Wastewater PondE EvapoÛanspiration
E other
Final Disposalby
E cisternE Stream or CreekE well E Spring
E Community Water System Name
Water Source & TYPe
Will Effluent be discharged directly into waters of the E Yes E ttoState?Effluent
CERTIFICATION
Anolicant acknowledges that the completeness of the application is conditional gpgn such further
;i#ä;ï;*;;d ;äã''tï;;;iläìf "nã-ràþo'ts "s
may þç required by the local health department to be
il;ä;:iåi;;jri;;ï; iï;" ãpiii.ãnt-ãi ¡v tn" loóal health dcpartment for pu.rposed.of the evaluation
ääËä äpËt¡ãåïiãü; ã,itìiãiiiiánò" "f thó permit is subject to such terms and conditions as deemed
necessary to insure .orpl¡rniäwith rules ánd regulations made,.information and reports submitted
nãiã*iir.,'r"d requ¡re¿ iå tË *¡ritteã by the _ap-pl.icant are or will be represented to be true and
äoiöåt toìr.,ó ¡"rt or rîtno*le¿eäan¿ 'belief ånd are designed to be relied on by the.local
ãã"Jrt"iã,ìt of heatth ¡"'u"åLjàtiÃäihé tar" for purposes oi issuing the. permit a,pplied for herein. I
il=,.lñlri'r;ä;;tä"äir.r.i ã"v r.tiìrìiriion or mìsrepreientation m,ay result in the denial of the
åîrliiätäñãir"uó.rtion äi "ñv
p"irit granted based upon said ápplication and legal action for perjurv
as provided bY law.
I hereby acknowledge that I have read and understand the Notice and certification above as well as
have provided the required information which is correct and accurate to the best of my knowledge'
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Property Owner Print and Sign Date
?P l7?. b)d8 rl zß t1I
OFFICIAL USE ONLY
SpecialConditio4s:"""ö;¿ -4,++6¿t^¿'
{i gt "f ¿"n-{t{ione
Fees Paid .oDTotal Fees:l2)-ooPerk Fee:Permit Fee
l27.oo Balance Due:
ø
lssue Date:Permit:Building Permit
BUILDING/ PLANNING DIVISION
Signed Approval
zþlø¡q
Date