HomeMy WebLinkAboutApplicationRFCEVED
ÐËt t 3 3.02Ê
..,îfi fi l,ç,.P,,î,o#ilJ,ï
L95 W. 14th Street
Rifle, CO 8L650
(s70) 62s-s200
#¿*f¡d.sc Í€eæf;tk
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8160L
{e70) e4s-6614
Gxrrteild C*untï
TYPI OF SYSTEM CONSTRUCÍION
n New lnstallation Alteration ¡ Repair
E Transient Usetr Dwell
BUlLDllì16 USA6E TYPE
n Comm,,/lndustrìal n Non-Domestic
I other Describe
vf,D
Property rr'*
Mailing Cc)6-¿ 9 ca
Email Address:¿.rtOOê r
ì
Mailing Address;
EmailAddresst
5¿. ¡,\ à t- |r"- I L^t ^t'tr 2-.phone:(77ö\ ¿)et{{2 cí
MailingAddrett, Ç L3 ¿c>(f e f L,t "" C o
EmairAddress' ß ruaa @ brr- t'nC - 6¿ r
Assessor'sParcelNumber:23iSoltooOCg Sub, - lot - Block :
BuildingorServiceType:#Bedrooms:-GårbaEeDisposal(Y/Nl
Was an effort made to connect to the Communíty Sewer System:
o
Englnee
Distance to Nearest Community Sewer System;
Âtì/D DÉsCBÍPTIOÍ{
lob Address:teP
tr Well E Spring E Stream or Creek E CisternPotable Water Source
& Type fl Community Water System Name
ß*rfi*ld ü*unty flr;å:lic H*xì¡h *ep*rtm*ni * uv*rhing t* pron*t* hs*lth and prs$*ilå diçs;¡se
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
rty Owner Print and Sign Date
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 by law.
OFFICIAL USE ONIY q-Þ, * 1l,ro c,c. tzf67 /zazt
Special Conditions:
Permit Fee:* -î5.""Total Fees:
+15."o
Fees Paid
* 71, ""
Building Permit
gÞFÉ "726t
OWTS Permit:
Seer --7zt+1
lssue Date:Balance Due:+d
Garfield County Publ¡c Health Department
Signed Approval Date