HomeMy WebLinkAboutApplicationRECEIVED
MAR 1 0 ?t22
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Pablic lIeølth
195 W. 14th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-6614
OWTS PERMIT APPLICATION
Gurfield County
TY..PEOF CONSTßUCTION
E New lnstallat¡on Alteration tr r
EI Dwelling D Transient Use tr Comm./lndustrial tr Non-Domestic
fl Other Describe
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Property
Email Address:
Mailing
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ZS.MailingAddress
EmailAddress:
('110 t 14Ø .- 7ð 1¿i
MailingAddress:
Email Address:
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
roomsz-S-{Garbage Disposal(Y/N I t{
)i:
No
Building or Service
Job Address:
aúôAssessor's Parcel Number
n weil [J Spring [f Stream or Creek D cisternPotable Water Source
&Type { Community Water System Name Ll¿-r,l Lank ftl¿-+^ I-ttA
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 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 ¡ssuance 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 any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon saíd application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Not¡ce and Certificat¡on above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
3 [to IzÒLL
Property Owner Print and Sign Date
P*gi: 5 i:i'i
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Special Conditions:
'åiä,,o Total Fees:
7S-
Paid:oôFèes
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Buildlng Permit
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OWTS Permit:
ó€ ?1 .'t 39 3
lssue Date:Balance Due:+6
Signed Approval
Garfield County Public Health Department:
a
Date
03/21/2022