HomeMy WebLinkAboutApplication-PendingGarfield County
195 W. 14th Street
Rifle, CO 81650
(s70) 62s-s200
Public Health
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7o) e4s-6614
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation Alteration
BUIIDING USA6E WPE
tr Non-Domestic
t1^
Comm./lndustrialE Transient Use¡ Dwelling
n other Describe
rnrvolvED PARTTE \-L.¿-11 I ¡
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Property
MailingAdd
Email Address:
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CO
MailingAddress:
Email Address:
Contra
Mailing Address:
EmailAddress:
Was an effort made to connect to the Community Sewer System:
o
8
BlockAssessor's Parcel Nu
Phone:
0
PTIONPRO¡ECT TOCATION AND
lob Address:
6arbage Disposal(Y/N)_Building or Service Type:
Distance to Nearest Cornmunity SewerSystem:
fl Spring n Stream or Creek E Cisternú WellPotable Water Source
& Type f{ommunity Water System Name \-U [2)
Garfield County Public Healih Department - working to promote health and prevent disease
CERTIF¡CATION
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
neceisary to insure compliance with rules and regulations made, information and reports submitted
herewith'and required to be submítted by the applicant are or wíll 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 issuíng the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the deníal of the
application or revocation of any permit granted based upon said appfication and legal action for perjury
as provided by law.
acknowledge that I have read and understand the Notice and Certification above as
the required information which is correct and accurate to the best ofhave
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Property nt and Sign
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OFFICIAL USE ONLY PAIÞ * ? ç.oô C:lt ,lö ZôS e ozlotI?ãL.¿F
Specíal Conditions:
Permit Fee:
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Total Fees:
.$'?fr co Fees Paid:
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Building
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Permit
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OWTS Permlt:
,5Ë.Pr.?34'lx
lssue Date:Balance Due: â
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Garfield County Public Health Depãrtrnent:
Signed Approval Date