HomeMy WebLinkAboutApplicationRECEIVED
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GARFIELD COUNTY
COMMUNITY DEVELOPMENT
195 w. l-4th street
Rifle, CO 8L650
(970) 62s-s200
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 8L601-
(970) 94s-6614
OWTS PERM IT APPLICATION
Gørfield County
TYPE OF SYSTEM CONSTRUCTION
tr Alteration tr RepairNew lnstallation
tl Comm./lndustrial tr Non-DomesticDwelling
BUILDING USAGETYPE
E Transient Use
E Other Describe
INVOLVED PARTIES
Property Y10
Mailing Address
Email Address:
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Mailing Address:
Email Address:
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Mailing Address
EmailAddress:
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PROJECT TOCATION AND DESCRIPTION
Job Address:1
Assessor's Parcel Number ztlq lz4 <tl ðÕ-fu6 ßrOËF UrÉ{rJ FÊffirlot 3 slock
Building or Service ryper S , F,R- *Bedrooms: f Garbage Disposal(Y/N) VË5
Distance to Nearest Commun¡ty SewerSystem:MILÉ5
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
{weu E Spring E Stream or Creek 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 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 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
well as have provided the required information which is correct and accurate to the best of
my knowledge.
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Property Owner Print and Sign Date
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Spec¡al Conditions:
Permit Fee:
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Building Permit
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OWTS Permit:
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lssue Date:Balance Due:*y
Garfield County Public Health Department:
Signed Approval Date
04/13/2022