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GARFIËLD COUNTY
EOMMUNITY DEVELOPMENT
L95 W. 14th Street
Rifle, CO 81650
(e7o) 62s-s200
201"4 Blake Avenue
Glenwood Springs, CO 8L60L
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OWTS PERMIT APPLICATION
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i BUIIDING USAGE TYPE
i E TransientUse i E Comm./lndustrial Non-Domestic
GørrteH County
Describe
INVOTVED PARTIES
Property
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Mailing Address:
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i PROJECT TOCATION AND DESCRIPTION
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Assessor's Parcel N
Building or Service +-\'
Distance to Nearest Community SewerSystem:
Was an effort made to connect to the Community Sewer System:NJc'l
Disposal{Y/Nl Y
E Stream or Creek E Cistern
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Name
: 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 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 Cert¡f¡cat¡on 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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Special Conditions:
Permit Fee:
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Total Fees:
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Fees Paid:* ¡23 .oo
Building PermitgLRE-?12:OWTS Permit:
5€?r-112.+
lssue Date: Balance Due:.+ø
Garfield County Public Health Department:
Signed Approval Date