HomeMy WebLinkAboutApplicationGarfield Coanty
195 W. 14th Street
Rifle, CO 81650
(970) 52s-s200
Puhlic Health
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970ì.94s-66L4
New lnstallation tl Alteration EI Repair
BUITDING USAGEWPE
B Dwel ling E Transient Use Comm./lndustrial EI Non-Domestic
I tr other Describe
IT{VOLVED PARTIES
Property o -01-1
, Malling Address o -S i'\Lo (iøSu
Email Address:
MailingAddress:
Email Address:
Engineer
MallingAddress:ú 6r,nt L?
Email Address:pS
PRO.IECÍ TOCATION Af{D DESCRIPTION
Job Address:
' Assessor's Parcel 2t71zy o
Building or Service
Distance to Nearest Community SewerSystem:4 nttíl¿>
Was an effort made to connect to the Community Sewer System:
, &Type
It otsposary@) !-
Y¿¡
Potable Water Source .ED Well E Spring I Stream or Creek E Cistern
E Community Wðter System Nâme
Garfield County Public Health Department - working to promote health and prevent disease
CEñTIFICATIOñI
Applicant acknowledges that the completeness of the application is conditional .upo!'t such further
ridndatory and addiiional tests and réports as may be required by the local health department to be
made andÎurnished by the applicant or by the local health department for purpose of the evaluation of
the application; and tlie issuánce of the permit is subject to such terms and conditions as deemed
neceisary to iniure compliance with rules and regu.lations made,_informat¡on and.reports submitted
herewith'and required tó be submitted by the -apþlicant are or will be rep.resented to be true and
correct to the beit 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 falsifiıation or misrepresentation may result in the denia.l of the
application or revocation oi 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 Not¡ce 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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Owner Print Sign Date
OFFICIAI Ugg ONLY P¿ . .t t23,oô ¿¡a a tgl t2/zt /zoz-t æ
Spccial Conditions:
Perm¡t Fee:
* tz?.oo
Total Fees:*lz3.oa Fees Paid:4lzz,"6
Building Permit
9t (4--7230
OWTS Permit:
t6?r-7 z8 I
lssue Date:Balance Due:.+-d
Garfield County Public Health Departmentl
Signed Approval Date