HomeMy WebLinkAboutApplicationGørfield County
195 w. 14th street
Rifle, CO 81-650
(970) 62s-s200
Public Hesltlr
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970')945-66t4
BUITDING USAGE TYPE
E Transient Use
0¡,
! Non-Domestic
INVOLVED PARTIES
Property Own
Mailing
Phone:
Sut
2 7
e zVS
7
. Ce nirø L x ,--t
EmaitAddress: dSlra nS t?, d ( SAa...J.¿-olryl
WPE OF SYSTEM CONSTRUCTION
New lnstallation Alterationtr trtrRe
tr Dwelli n Comm./lndustrial
+-Describe
Co
Mailing Address
Email Address:
e: (-)
ry1
Engi Phone:
Mailing Address: æ2 G o qs
Email Address:d s (2t-+eo
PROJECT TOCATION AND DESCRIPTION
Job Address:T-7'7 e -¿R zqï-- neurã;7-l¿ Ca .
Assessor,s parcerNumb eît z I zsl g loooåi*on e"r*t t v ,x W5;Ð U ztw\foÑ
Building or Service
Distance to Nearest Community SewerSystem:N.¿.
Was an effort made to connect to the Community Sewer System:
rooms; Ô Garbage Disposal(Y/N) Ñ
92weu n Spring E Stream or Creek n CisternPotable Water Source
& Type ! Community Water System Name
Garfield County Public Health Depaûnren1 - working to promole health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additlonaltests 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
neceisary 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 a.pplied for herein. I
fuither understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permitgranted based upon said application and legalaction 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 required information which is correct and accurate to the best of
my knowledge.
2o L/
Property Print and Sign
OFFICIAL UsE ONLY Pd . $l¿A,oo c,c, n/tSlzozt æ
Special Conditions:
Permit Fee:* lzg. go
Total Fees:
f ra3.oP
Fees Paid:*lz3.op
Building Permit
9L96,- 1?-4 g
OWTS Permit:
seçr4?*+l
lssue Date:Balance Due:*f
Garfield County Public Health Department
Signed Approval Date