HomeMy WebLinkAboutApplicationRECEIVED
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Public Health195 W. L4th Street
Rifle, CO 81650
(e70) 62s-s200
201-4 Blake Avenue
Glenwood Springs, CO 8160L
(97Ols4s-66L4
OWTS PERM IT APPLICATION
Gørfield County
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation tr Alteration ! Repair
BUITDING USAGE TYPE
Dwelli E Transient Use ¡ Comm./lndustrial tr Non-Domestic
fl Other Describe
INVOLVED PARTIES
t
Property
EmailAddress:
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- Phone:0-7 L51
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Contractor:
Engineer:_
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Mailing Address:
Email Address:
PROJECT LOCATION AND DESCR¡PTION
Was an effort made to connect to the Community Sewer System:
Garbage Disposal(Y/N
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Job Address
Distance to Nearest Community SewerSystem
Building or Service 5tÞ9r¡¿Ê
Assessor's Parcel Numbe r:2lb lo? 303OOb s
! Well fl Spring ! Stream or Creek E cisternPotable Water Source
& Type
fCommunity Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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 tó 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 maylesult 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
Property r Print Date
oFFlclAL UsE oNtY P{. $ lZ3,oo cl¿* taOE 6Wt/'"þ ze-åûÞ
Special Conditions:
Permit Fee:
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Total Fees:
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Fees Paid:* ¡z-3.æ
Building Permit
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OWTS Permit
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lssue Date:Balance Due:
Garfield County Public llealth Department:
Signed Approval Date
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