HomeMy WebLinkAboutApplicationRECEIVED
GARFIELD COUN
COMMUNITY DEVELOPM
Public llealth
195 w. 14th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Spríngs, CO 81.601
(e70le4s-6614
OWTS PERM ¡T APPLICATION
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WPE OF SVSTEM CONSTRUCTION
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BUILDING USAGEWPE
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Elother Describe
INVOTVED PARTIES
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PROJECT TOCATION AND DESCRIPTION
Was an effort made to connect to the Commun¡ty Sewer System:
Distance to Nearest Community SewerSystem:Aifte, - çn'=x\ r>
Disposal(Y/Nl fV
Job Address:
Building or Service
Assesso¡rs Parcel
I Stream orCreek E cistern/.wel [1 Spring
E Community Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CËRTIFICANON
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 subm¡tted 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 falsificatíon or misrepresentation may result ín 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 Print and Sign
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Special Conditions:
Permit Fee:
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Total Fees:i lLs9"Fees Pald:i lz3.e"
Building Permit
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OWTS Perm¡t:
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lssue Date:Balance Due:
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Garfield County Public Health Department:
Signed Approval Date
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8/26/2022