HomeMy WebLinkAboutApplicationGøffield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
Community Development Department
108 8th Street, Suite 401
RECEIVED Gt"n*ood Springs, co 91601
|JUN 1 I ?ot$ ***.':l,?*TÍ-'.-:,t"'l.."".,
GAR FIELD gOUNTV
GOMMU ucfloN
Å Repairtr AlterationNew lnstallationtr
WASTE TYPE
tr Non-DomesticE Transient Use tr Comm./lndustrial! Dwelling
E Other Describe
INVOTVED PARTIES.z) ¡AI
Property Owner:
Mailing Address:
Phone:I
Email Address:
Contractor:Phone:
Mailing Address:
Email Address:
Engineer:Phone: ( )
Mailing Address:
Email Address:
Job Address:
Assessor's Parcel Number: Sub'Lot _ Block
Building or Service type, fu,lyW hofü<- #Bedrooms: 7- Garbage oisnosalfi@-
D¡stance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:rb
Type of OWTS 4 Sept¡cTank E Aeration Plant E Vault E Vauh erivy tr Compost¡ng Toilet
E Recycling, Potable Use E Recycling tr P¡t Pr¡vy E lnc¡nerat¡on Toilet
E Chemical Toilet E other
Ground Conditions Depth to 1st Ground water table Percent Ground Slope
Final Disposalby E Absorpt¡on trench, Bed or Pit E Underground Dispersal E Above Ground Dispersal
E Evapotranspiration E Wastewater Pond E Sand Filter
E other
Water Source & Type lf.wett E Spring E Stream or Creek E Cistern
E Community Water System Name
Effluent Will Effluent be discharged d¡rectly into waters of the State? E Yes E lt¡o
PROJECT NAME AND
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditiona! upon such further
niai¿ãtory ãnd additi-ional test and reþorts a.s qay be required by the local health de.pa-rtment to be
mã¿e andÎurnished bv the applicant ôr by the local health department for purposed of the evaluation
ôt ttlã ãpbl¡cation; and the isiüance of thé permit is. su.bject to such terms and conditions as deemed
necessarv to insuie compliance with rules ánd regulations made, information and reports submitted
freià*¡itr'and required tó be submitted by the apþlicant are or will b.e repres.ented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the local
ããóàrtmãnt of health in'evaluatin!'the same for purposes oi issuing the permit applie.d for herein. I
further understand that any falsifiıation or misrepresentation may result in the denial of the
appiiðation or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowtedge that I have read and understand the Not¡ce and Certification above as well as
have provided the required information which is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
t,
oôOFFICIAL USE O
Special Conditions tt
Fees oo
a
ooTotal Fees:rtlSFee:oôPerk
-x tsn.
eg$tPe'oo
F- ).
lssue Date:-Xl tnltQ
Balance Due:éd.*Building Permitlù!n Seotic Permit:¡E.Þìr-ffi
6/8-åBUILDING/ PLANNING
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