HomeMy WebLinkAboutApplicationGarfield County
Community Development Department
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-county.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Er -Flew Installation /404.-cxfe,..fi
WASTE TYPE
0 Transient Use
0 Alteration
0 Comm./Industrial
0 Repair
0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: f714r//jc�.vsTQ%•+;
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or 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
necessary 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 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 squired information w-ich is correct and accurate to the best of my knowledge.
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Property Owne
int and Sign
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Date 1
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
:23, OD
Building Permit
Perk Fee:
Septic Permit:
Ser— s
BUILDING/ PLANNING DIVISION:
PD
Total Fees:
Issue Date:31 ) 11
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19-3.Qn)J11 05, aIThI1l
Fees Paid:
(2-3 oz
Balance Due: .v
3-7- 2o)q
Date