HomeMy WebLinkAboutApplicationGaffield Coun$
Public IIeaIth
L95 w. 14th Street
Rifle, CO 8L650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERM IT APPLICATION
WPE OF SYSTEM CONSTRUCT¡ON
New lnstallation tr Alteration tr Repair
BUILDING USAGE WPE
Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
¡NVOLVED PARTIES
Email Address høto(
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uôhProperty Owner
o lLl(Mailing Address:
6r,,l^ef PhoneContra
Mailing Address:
Email Address:
Email Address:
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Mailing Address:
Engineer
Assesso r's pa rce I N u m b
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I I 2'1W*j s u b.-Lot-Block
Was an effort made to connect to the Community Sewer Syste
Garbage Disposal(Y/N) Y
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Building or Service Type (
PROJECT TOCATION AND
Job Address:
Distance to Nearest Community SewerSystem:
! C¡sternEf Well tr Spring E Stream or CreekPotable Water Source
& Type E Community 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 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 anyfalsification 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.
Tfè^r ?rr**r,*o Tozs-
DateProperty Owner Print and Sign
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Special Condit¡ons:
Permit Fee:
¿r l2-3.æ
Total Fees:t lz3.@
Fees Paid:+lzz.ñ
Building Permit
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OWTS Permit:
5e?7 --t3?+
lssue Date:Balance Due:*d
Garfield County Public Health Department:
Signed Approval Date
l'll:r'5 o1 .1
I ¡trlr,ilri iÌ¡'r' .l(l Ì 1
03/11/2022