HomeMy WebLinkAboutApplication195 W. l-4th Street
Rifle, CO 81650
(970) 62s-s200
Public Heølth
REGEIVED
F r'"8 '¡ e 2022
GARFIELD COUNTY
TOMMUNITY DEVELOPMENT
2014 Blake Avenue
Glenwood Springs, CO 81-601
(970) 94s-6614
OWTS PERMIT APPUCATION
BUITD¡NG USAGE WPE
Gurfield County
TYPE OF SYSTEM CONSTRUCflON
Repairntr AlterationNew lnstallation
I Non-Domestictr Comm./lndustrialE Dwelling E Transient Use
E other Describe
INVOLVED PARTIES
Property
Mailing
Email Address:
ô
MailingAddress ?o ßore ¿t7L PararluJe.¿o 9lb3{
Email Address:
Phone:M.al
Mailing Address
Email Address:.l¿r r Ð I^tl-ìnc^ lot*4,
PROJECT IOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel
Buitding or service '¡vpe, fuSi J¿ttJ¡al *Bedrooms: I Garbage Disposal(Y/N I Y
Distance to Nearest Community SewerSystem:{ *tloÂ
Was an effort made to connect to the Community Sewer System:/"s
Potable Water Source
& Type
F weil tr Spring fl Stream orCreek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is.conditional .rPo.n such further
n'iandatory and additional tests and reports 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 issuárice of the pèrmit is subject to such terms and conditions as deemed
neceisary to insure compliance with rulés and regulations made, information and.reports submitted
herewith'and required tò be submitted by the applicant are or will be represented to be true and
correct to the belt 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 apRlie.d for herein. I
fuither understand that any falsifièation or misrepresentation may result in the denia.l 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 knowledge.4tL z/tz/zo
Property Owner Print and Sign Date
Special Conditions:
Total Fees:r lz7,o.Fees Paid:
*t23.æPermit Fee:|1t7,6
lssue Date:Balance Due:+r'OWTS Permit:
36''|t'- 13çê.
Building Permit
Av?E'1168
Garfield County Public Health Department:
Signed Approval Date
fir-ig.e 5 o1-.1
¿ìr;cl:¡úe{l l}*c 3$i ::
02/28/2022