HomeMy WebLinkAboutApplicationGPublic Healtharfield County
195 W. 141h Street AS 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUMON_
❑ New Installation _ _❑_ Alteration Repair _
j BUILDING USAGE TYPE
Dwelling ❑ Transient Use ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTi
r - - -
Property Owner: \ • �' Phone: (� 0 )L--
MailingAddress: 7CcLU-V, IIq s % I-L ' .c , )(95�
T
Email Address: i rGSS^] r L C C�IV1
Contractor: +n,;__Cf'\ �6, r�ti1�[Phone• ( �
Mailing Address:
Email Address:
Engineer: Q4 i`d Phone: �)
MallingAddress: 5 c)2c' w` .�� G1-et)iuooCAI .
Email Address: L: �' i V, e, `� N\a �u� AM . C C'
IPPROJECT LOCATION AND DESCRIPTION
Job Address: ": 2(,—
Assessor's Parcel Number: kt�� 'a«'cat ' o tz a: 1 11 IC-6 Lot ,� Block
Z, 7z Le CGtJn kcr_�r1 ' y 11
�ilding or Seuvicqjype b'it(C . Scl LG_F, 7- _ #Bedrooms: Garbage Disposal(Y/N)�
�i�tr ��r22 ll �
Distance to Nearest Comttiunii S werSystem:
Was an effort made to connect to the Community Sewer System:
Potable Water Source 1, Well ❑ Spring ❑ Stream or Creek ❑ Cistern
& Type ❑ Community Water System Name '
Garfield County Public Health Department — working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional tests 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 purpose 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 bylaw.
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
Rlo-av-� �css
Property Owner Print and Sign Date
OFFICIAL USE ONLY AJ # TS. SP
CX1W 1032 o IS so21
Special Conditions:
Permit Fee:
'total Fees:
Fees Paid;
Building Permit
MA
OWTS Permit:
SEPr- Oq4
Issue Date;
Balance Due:
Garfield County Public Health Department:
Signed Approval
Date
Paae 5 of 3
Updated Dec 2013