HomeMy WebLinkAboutApplicationMAY i I lljz:l
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
REC'
1-95 W. 14th Street
Rifle, CO 8L650
(970) 62s-s200
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERM IT APPLICATION
Gørfteld County
TYPE OF SYSTEM CONSTRUCTION
New lnstallation tr Alteration tr Repair
Éu¡lorruc USAGE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property
Mailing Address
Email Address:
e:Contra
Mailing Address
Email Address:
(*
a
c-d)
Mailing Address
EmailAddress:
PROJECT D
Was an effort made to connect to the Commun¡ty Sewer System:
N /e'¡)
Assessor's Parcel Num L
Disposal(Y
Distance to Nearest Community Sewer System
Job Address
Building or Service
ffpert tr Spring E Stream or Creek E Cistern
lJ Community Water System Name
Potable Water Source
& Type
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 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
oFFtc¡ALUSEONLY ?hto + l23.èâ c,c, 64tz/z¡z.z æ
Special Condit¡ons:
Permit Fee:t lz3.æ
Total Fees:* fz3.æ
Fees Paid:
4 t 23.ao
Building Permitgrrg."SZr OWTS Permit:
sE?î .1s?-l lssue Date:Balance Due:1d
Garfield County Public llealth Department
Signed Approval Date
, l 'r .,Ì.,
I , ,: rt ' i' :l
06/06/2022