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GARFIELD GOUNTY
COMMUNITY DEVELOPMENT
RECEIVED
195 W. 14th Street
Rifle, CO 81650
(s70) 62s-s200
Pablic Heulth
o WTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation
INVOTVED PARTIES
Property
Mailing r{EJ\?-
Email Address:'ït"'\L"oâ ó{.o l" {^r
2014 Blake Avenue
Glenwood Springs, CO 81601
(s70) 94s-6614
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Gurfield County
rtr Alterat¡on
BUILDING USAGE TYPE tr Comm./lndustrialE Dwelling E Transient Use Non-Domestic
E Other Describe
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Mailing Address:
Email Address:
Mailing Address:
Email Address:
(Enginee
was an effort made to connect to the Community Sewer System:fìo
rl Disposal(Y/N) Y
PROJECT TOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel Num
D¡stance to Nearest Commun¡ty SewerSystem
Building or Service
-8 ^" ,1e
E CisternE Spring El Stream or CreekI WellPotable Water Source
& Type E CommunityWater System Name
Garfield County Public Health Department - working to promote health and prevent disease
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Applicant acknowledges that the completeness of the application is conditionalupon such further
niandatory and additional tests and réports as may be required by the local health department to be
made and?urnished by the applicant or by the locàl health department for purpose of the evaluation of
the application; and ttie issuáñce of the pèrmit is su.bject to such terms and conditions as deemed
neceis'arv to inlure compliance with rulès and regulations made, information and reports submitted
herewith'and required tö be submitted by the apþlicant are or will be represented to be true and
correct to the belt of mV knowledge and belíef and are designed to be relied on by the local
deoartment of health in'evaluating the same for purposes of issuing the perm¡t applied for herein. I
further understand that any falsifióation or misrepresentation may result in the denial of the
application or revocation of any permit granted bãsed upon said application and legal action for perjury
as provided by law.
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the requ¡red information which is correct and accurate to the best of
my knowledge.
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Property Owner Print and Sign
>.
Date
OFFICIAL USE ONIYP'l' CK* I l|rçee
Special Conditions:
Fees Paid:
+15e
Total Fees:
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Balance Due:
-æOWTS Perm¡t:
sePT- 6?"[?
lssue DateBuildlng Permit
u/r
Garfield County Public Health Department:
Signed Approval Date