HomeMy WebLinkAboutApplicationGuffield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
REGENED
Er:tt l- T ?tltl
,ntll*t'g'ty'lI-'
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
l970l94s-82t2
www.Rarfi eld-counW.com
TVPE
w:PE OF CONSTRUCTTON
New lnstallation u Alteration EI Repair
'wAsr
X Dwelline I E Transient Use tr Comm./lndustrial tr Non-Domestic
/E oth"r Describe
INVOTVEO PARTIES
Property Owner:
Mailing Address:
Email Address:
3aø{e
Phone: { )Contractor:
Mailing Address:
Email Address:
Engineer:Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATIOU ,t ^ I o¿a A ^ta t
Was an effort made to connect to the Community Sewer System
Block
o¡sposa(v/r'¡ I N
Lot
Garbage#Bedrooms: Z
Àl.>
3 m,-va>
Job Address:
Assessor's Parcel Number:
Distance to Nearest Community Sewer System:
Building or Service Type:
Septic Tank nE Aerat¡on Plant E Vault E vaultPriw
E Recycling, Potable Use El lncineration ToiletEI Recycling EI Pit trtvy
Composting Toilet
[] Chemical Toilet El other
Type of OWTS
Percent Ground Slope f¿tGround Conditions Depth to lst.Ground water table -jiltrf,&4tlüll
E UndergroundDispersal E Above Ground Dispersalfl AbsorRtion trench, Bed or Pit
El Wastewater Pond El Sand FilterEl Evapotransp¡rat¡on
E Stream orCreekE Well E Spring CisternWater Source & Type
E Community water System Name
Will Effluent be discharged directly into waters of the State? EI Yes NoEffluent
Final Disposal by
û other
¡ CERTIFICATION
_t
ness of the application is conditional upon such further
as may be required by the local health department to be
purposed of the evaluationthe local health de partment for
permit is subject to such terms and conditions as deemed
necessaryto 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 required information is correct and accurate to the best of my knowledge.
Property Owner Print and Sign Date
Pi)2V7 oo,Flt¡5 ),4
OFFIC¡AL USE ONIY
Special Conditions:
Permit Fee:
l7z ,;o l{A ooPerk Fee:Total Fees:27V c¡r¡
Fees Paid:
2-77 Õo
Building Permit
BLR.C- 5q Tç
Septic Permit:
SgÞ7 54zto
lssue Date:
r ct le,rv//9
Balance Due:.
ø
BUILDING/ PLANNING DIVISION:/aJ7:À.ll
DateSigned