HomeMy WebLinkAboutApplicationRECEIVED
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195 W. l-4th Street
Rifle, C0 81650
{e70) 62s-s200
Public Health
OWTS PERM IT APPLICATION
201-4 Blake Avenue
Glenwood Springs, CO 81601
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SYSTEM CONSTRUCTI
lnstallaiiãn n Alteration t
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n Repair
Gørfield CountJ/;#,¡r.l
BUILDING USAGE WPE
Dwelling fl Transient Use n Comm./lndustrial tr Non;Domestic
[ 0ther Describe
PARTIES
Property Owner
Mailing Address
Email Address:
Contractor;
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ne: {
Mailing Address:
Email Address
Engineer:
Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
Job Address
Assessor's Parcel Number:2lqtalt ln 7ôo:l 5ub.
Building or Service Type Ke¿n \.,
Distance to Nearest Community SewerSystem:
Was an effort made to connect to the Communíty Sewer System
#Bedrooms:4 Garbage Disposal{Y/N t/
d-Lo lw
n Stream or Creek [] CisternPotable Water Source
& Type S.Community Water System Name
Phone:
É-welt n Spring
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further
nìandatory and additinnal 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 tl'ie issuánce of the permit is subject to such terms and conditions as deemed
neceésiry to insure compliance with rules and regulations made,.information and.reports submitted
herewith'and required tô 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 applied for herein. I
fulther understand that any falsification or misrepresentation may result 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
wellas have provi ded the required information which is correct and accurate to the best of
my knowl
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Property Owner Print and Sign Date
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Specíal Conditions:
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Total Fees:Fees Paid:I l23,.oPermit Fee:
Sre3.èo ,"*"ï"Ulssue Date:Building Permit
tst*,E.?36{
OWTS Permit:
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Signed Approval
Garfield County Public Health Department:
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Date
03/08/2022