HomeMy WebLinkAboutApplicationGarfield County
Publíc Health
195 w. l-4th Street
Rifle, CO 81650
(e70) 62s-s200
20L4 Blake Avenue
Glenwood Springs, CO 8160L
(e70) e4s-661.4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation .E[ Alteration n Repair
BUITDING USAGE WPE
! Dwelling Û Transient Use ¡Comm./lndustrial !Non-Domestic
(Otfrer Describe T
INVOTVED PARTIES
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Mailing Address
Email Address:
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Mailing Address
Contractor:
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Mailing Address:
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PROJECT TOCATION AND DESCRIPTION
Was an effort made to connect to the Communíty Sewer System:
t/a
Garbage Disposal(Y/Nl Al
t¡/a
Job Address:
Distance to Nearest Community SewerSystem:
Building or Service Type
Assessor's Parcel Number:tzl00a
#Bedrooms: ø
n Well I Spring ! Stream or Creek I CisternPotable Water Source
& Type EKÇommunity Water System Name ftu(P{# Lír^vtk-
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
mandatory-and additional tests and repofts as may be required by the local health department to be
made and furnished by the applicant or by the locál health depardment for purpose of the evaluation of
the application; and tlie issuânce of the pêrmit is subject to srich termi ancl'cônA¡i¡oñs ãidãemäd - -
necess.ary to.insure complìance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented tó be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of heaith in evaluating the same for purposes oi issuing the permit applied for herein, I
further understand that any falsifióation or misreþresentation maylesult in the d'ehial 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 Not¡ce and Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
Property Owner Print and Sign Date
Page 5 of3
Updated Dec 2013
7s.oo
Special Conditions:
Permlt Fee:
$?s,rq
Building Permit
BLße-"1ôt
OWTS Permit:
s€?Î. ? 31 Ò
Total Fees:Fees Paid:
{J5-,o"$ ls.oo
lssue Date:Balance Due:
Garfield County Public Health Department:
Signed Approval Date
03/14/2022