HomeMy WebLinkAboutApplicationGurfield Cownty
195 w. 14th Street
Rifle, CO 81650
(e70) 625.s200
Publíc Heølth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
,(970)e4s-6614
TYPE OF SYSTEM CONSTRUSF¡ON
New I tr Repair
BUILÞING USAGETYPE
nduslrial I E Non-DomestlcE Trans¡ent Use
El other Describe
rNl/owED
Property Owne I 714t 279 8130
Email Addres¡¡BTslllahêt@SRCMall.tOM
( !?a"J_-q{e-ags9--
Malllng Address:
3s60 Mldland Ave..alloñr.ñ^r{ FlnrlndR'
Ëmåil Addresr:dôv¡drlppyconshucllon@gma¡l.com
ZåncsnÉllr I 970 I S¡t55700
MalllngAddress:
Emell Address:Tsz@za-englneerlng.com
Potable Water Source fl Well E stream orcreok Gl¡tern
tr CommunltyWatéf System Näme&Type
Was an effort m¡de to con¡ect to the Communlty Sewer System: . 19 .. ',
IN
DisposallY/Nl-
Dlstance to Nearest Çommunlty SewerSystemr 6ml
AND DESCRIPTIONPROJECT
JobAddresel
240920200165Assessor's Palcel
Shop and StorageBulldlng or Serulce
Garfield County Public Health Depârtment - worklng to promoto health and prevenl disease
Applicant acknowledges that the completeness of the aoplication is cond¡t¡onal uoon such further
ria'ndatorv and additionaltests and reports as 1nav.È,-ri{üit"ft¡litré.19!9t-trealth department tobe
ilf;J;,*tilr]1äft"f 'JfHIiïUÏlt,*llæ:ll"{:r,tr'¡l:"*'.um'le*'i,i""'"','l5i""'
necessarv ro insure.orpi"ir,îiäilúr,'iuL,íiana regutãflãñi rn-au",.information and.reports submitted
ffiüiîi,'.ñ,1';;ä;iË:d iı i,i s-ùuäìiiåã ul, tir'ð apii¡C"nt are or will be rep.resented to be true and
ä;äii;îh;'b:;!i àl mi Ë"'"vilä;i;;J'Èiìet;Ål are designedto be rèlied on bv the local
de'artment of health in evaluating the same ror puiposıiä?ìlir¡ne tñe p"rmit applie.d for herein. I
Ë;ih;ï ñå;;;täiäît åï ;;; f.l;¡fiäiún or misreþreientat¡on mavlesult.in the denial of the
aootication or revocation äl å;ñffiít g;ånte,ã dã!ãd uóãn said ápplication and legal action for perjury
ai þrovided bY law.
CERTIFICATION
I hereby acknowledge that I have read and understand the Not¡ce and certilication above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
Property Owner Print and Sign Date
1lcct?t.ooFHClAt USE ONIY P ¡.
8,,-Condltlonr:Specl¡l t¡,tit:,wt t ICGtß6t ôvruf€{AÞC ?Orr4LtgtDGN¡â1t
Fees Pâld:
{ t2t.æ0recë
Total Feeg:
Srz 0o
Permlt Fee:
Balance Due:
.ilssuè Date:
¿tsséP
OWTS Permlt:
ñ A
Bu¡ldin8 Permlt
rt"
6arfield County Publlc Health
Signed Approval
Ottizlr¿Y¿l
Date