HomeMy WebLinkAboutApplication195 W. 14rh Street
Rifle, CO 81650
(970) 62s:5200
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Public Health
OWTS PERMIT APPLICATION
ot SYSTEM CONSTRUCflON
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EmallAddress:
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-6614
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Buildlng or Service
D¡stance to Nearest Communíty SewerSystem
Was an effort made to connect to the commun¡ty Sewer System:
Potable Water Source tr Well E Sprlng' E slreamorCreek I Cistern
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Garfield County
Garfìeld County Public Health Department - working to promote healih and prevent disease
Aoolicant acknowledges that the completeness of the aoplication is conditional upon such further
nia'ndatorv and additional tests and reportsås ft.F;ç.i"t"d by the-local health department to be
made and'furnished by t"r.t" ãËılüåñiãi uv thre ¡oiår t'lartl' depardment for.purpo.se oi the evaluation of
iüä:Ëii;;ffi;äãð ili"-il:r'J'[ıiiñq på.,"¡t ¡s suuiããCto ',i.¡' terrns and coñditions as deemed
nåieís'arv to iniure .o.npi'''îä*ìih-;iläànd 'ig,il:,tll:lljlft,ii[ffiË1,""åîL1ffifì,','J$,'åt"oiìãiuîiiJt-nïiãquirø tå be submitted bv the.ap
correct to the best or *í r,"rio,,üËåä;, äJ'b"ji;f-åñJ ãre deiigneo to be rälied on bv the local
deoartment of heatth in evatuating rhe same ro, Ëu'i*ãiäiìriuingihe,ngrmit ffilie.d lqr herein' I
Ë;{ñ.; ñåäil;äih;ï;;;'i"t;iìi'."iion ôr m¡sre'preientatíon may result in the denial of the
aooricarion or revocatiorï;iå"ni'åät-¡db;;;;äî b;;ãd uóofsa¡d a'pplicatlon and legal action for perjurv
ai þrovided by law,
CERT¡FICATION
I hereby acknowledge that I have read and understand the Notlce and certiflcation above as
well as have provided the required information which is correct and accurate to the best of
rny knowledge.
Property Owner Print and Sign DâtE
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OFFIC¡AI USE ONIY cßEN
Speclal Condítions:
Fees Pafd:I t2?.è"Totãf Fees:tt¿3.o"Permit Fee:{t2?.€
Due¡Balance
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lssue Date:,,owTS Petmlt:
sE?r- èlrl-u1 tBuildlng Permlt
Garfield CountY Publ¡c Heãlth
DateApproval
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