HomeMy WebLinkAboutApplicationRECEIVED
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GARFIËLD COUNTY
COMMUNITY
L95 W. 14th Street
Rifle, CO 81-650
(970) 62s-s200
Public Heulth
20L4 Blake Avenue
Glenwood Springs, CO 81.601
(s7ol94s-66L4
OWTS PERMIT APPLICATION ۟F
Gurfield County
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation ration tr Repair a
BUILDING USAGE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial EI Non-Domestic
E Other Describe
IINVOTVED
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Property
Mailing Address
Email Address:
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Mailing Address
Email Address:
Engineer: Y Phone:
EmailAddresr,
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Mailing Address
tlPROJECT ¡gç4f,lON ANÐ DESCBIPTIÞN
Was an effort made to connect to the Community Sewer System:
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Distance to Nearest Community SewerSystem
rooms:
Job Address: t (-- \. \./
Assessor's Parcel N
Building or Service
Potable Water Source
& Type
E CisternE Spring
E Community Water System Name
E Stream or Creek
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
nìandatory 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
neceisary to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required to be submitted by the apþlicant 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 evaluatinf 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.
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as
I as have p the req uired information which is correct and accurate to the best of
and Sign
OFFICIAT USE oôI
Special Conditions:-i I
Total Fees:s75, oo t""ü"f5,ooooPermit Fee:#75
lssue Date:"^Ð"fi."aoBuilding Permit
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OWTS Permit:SPt:+-:9æ
Garfield County Public Health Department:
Signed Approval
I
Date
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07/06/2022