HomeMy WebLinkAboutApplicationGørfield Counly ONS¡TE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
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TYPE OF CONSTRUCTION
tr New lnstallation Alteration E Repair
WASTE TYPE ,
E Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
/EIother Describe
INVOLVED PARTIES
^cLProperty Owner:
Mailing Address:
Email Address:
Phone:o glbçâ,
Email Address:
Phone:
cÐMailing Address:
Contractor:
Phone:Engineer:
Mailing Address
Email Address:
PROJECÍ NAME AND TOCATION
Was an effort made to connect to the Community Sewer System:
Llt tot) /.Job Address:
Assessor's Parcel Number
fBedrooms:Building or Service Type:
øt 7 Btock-
z;ttLo ItÍZ ¿lL[MÐ;fin '
Garbase Disposa I (Y/N )ì49J
Distance to Nearest Community Sewer System:
p SepticTank E Aerat¡on Plant E Vault E Vault Privy ! ComnostingToilet
E Recycling, Potable Use E Recycling E eit Rrivy E Incineration Toilet
Type of OWTS
E Chemical Toilet E other
Ground Conditions Depth to 1st Ground water table Percent Ground Slope
E Underground Dispersal E Above Ground Dispersalp Absorption trench, Bed or P¡t
E Wastewater Pond E Sand FilterE Evapotransp¡ration
Final Disposalby
E Other
tr well E Spring E Stream or Creek E CisternWater Source & Type
fi, Community Water System Name
Effluent Will Effluent be discharged directly into waters of the State? E Yes F *o
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional Vpgn such further
niandatory and addit'lonal test and reports as may be required by the local health de.partment to be
made and'furnished bv the applicant ôr 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
necessaiy 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 bebt 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 a.pplie.d for herein. I
furiher understand that any falsifiıation 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 required information which is accurate to the best of my knowledge
6/
Property Owner Print a Date
'J'
OFFICIAL USE ONLY oo
Special Conditions:I
Total Fees:
722s -
oo Fees Paid:ípcs.ooo6r75Permit Fee:Perk Fee:
¿tí;¡Ò.@
J^Aqlßlssue Date Bãlanceg Due:
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Euilding Permitr\lÈ Sept¡c Permit:qEtrr- s?r9
EUILDING/ PLANNING DIVISION 61
Date