HomeMy WebLinkAboutApplicationGurfield County
Public Heulth
195 w. 14th Street
Rifle, CO 81650
(s7ol62s-s2oo
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7ol s4s-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New lnstallation n Alteration ! Repair
BUILDING USAGE WPE
E Dwelling ! Transient Use n Com m./lnd ustrial ! Non-Domestic
! Other Describe
INVOTVEO PARTIES
Property
Mailing Address
Email Address:
Contractor : CIWU-a'tt\ Phone:
Mailing Address:
Email Address
Engi one:
(0 o/Mailing Address
Email Address:
PRO,ECT LOCATICIN AND ÐESCRIF'üON
Job Address:
Assessor's parcel Numb er' 9-17 3z 6 J60ö I 7 sub.-lot-Block
Garbage Disposal(Y/Nl yBuilding or Service Type
Distance to Nearest Community Sewer System
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
! Well í I snring n Stream or Creek fl cistern
! Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is.conditional upon such further
mândatory 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
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 permit granted based upon said application and legal action for perjury
as provided by law.
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.
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Special €onditions:
Total Fees
å ( 23,öo
Fees Paid:
Å t 23.""Permit Fee:
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lssue Date Balance Due:#øBuilding Permit
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OWTS Permit:
se?r -12+î
Garfield County Public Health Department
Signed Approval Date