HomeMy WebLinkAboutApplicationGarfield County
Public Heulth
195 w. L4th Street
Rifle, CO 8L650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81"601
(9701945-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration p Repair
BUITDING USAGE TYPE
fr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
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Property Owner
Email Address:
Mailing
Mailing Address:
EmailAddresrt
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tMailing Address:
Email Address:
PROJECÍ LOCATION AND DESCRIPTION
Assessor's Parcel Numbeï Zln ??LOO1:fl Sub. kntl¿rt Ocche¿':{ LotTR. ?5 alock
-Building or Service fype: PcsíAc¡¿<¿ fBedrooms:-lcarbage Disposal(Y/N) Y
Was an effort made to connect to the Community Sewer System:
2-'t7 Ò CILJob Address:
Distance to Nearest Community SewerSystem ìt lA
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E Cistern(weu tr Spring EI Stream or Creek
E Community Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional.upo.n such further
niandatory and addit'ronal 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
neceés'ary to insure compliance with rules and regulations made, information and reports submitted
herewith-and required tó 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 anyfalsifiòation or misrepresentation may result in the denialof 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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Property Owner Print and Sign Date
oFFtclAL usE ONLY ?d. *1g,* CftS ll . oy'oot lzszz-"þà
Special Conditions:
Permit Fee:
*'15crÐ
Total Fees:
+ 15, ê"Fees Paid:t 15,"Ú
Building Permit
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OWTS Perm¡t:scrr -1748
lssue Date:Balance Due:+,6
Garfield County Publ¡c Health Department:
Signed Approval Date
r;iil
2/11/2022