HomeMy WebLinkAboutApplicationRECËIVED
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GARFIELD COUNTY
COMIiiUNITY DEVËLOPIIENT
Publìc HeøIth
195 w. 14th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-6614
OWTS PERM IT APPLICATION
Gurfteld County
WPE OF SYSTEM CONSTRUCTION
DÍ New lnstâllat¡on E Alteration E Repair
BUITDING USAGEWPE
Dwelli E Transient Use E Comm./lndustrial E Non-Domestic
EI Other Describe
INVOTVED PARTIES Mo r e+r,
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Emall Address:
Wasan effort made to connect to the Communlty Sewer System;
æ J yrnt\ts
4 0
3 Dlsposal(Y/N)+
Assesso/s Parcel
Dbtance to llearest Communlty SewerSystem!
Bulldlng or Serulce
PROIECT IOCÀTION AND DESCR|PNON
Job Address:
A
tl Well tr Sprlng Û Stream or Creek E CisternPotable Water Source
&Type þCommunlty Weter System t{ame
Garfield County Public Health Department - working to promote health and prevent disease
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CERTIFICATION
I hereby acknowledge that I have read and understand the Notlce and Certlflcatlon above as
well as have provlded the requlred lnformatlon whlch ls correct and accurate to the best of
my knowledge.
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Property Owner Prlnt and Slgn Date
Applicant acknowledges that the completeness of the applicat¡on is conditional upon such further
nia'ndatory and addiUonal 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 ís subject to such terms and conditions as deemed
neceis'ary 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 rel¡ed on by the local
department of health in evaluating the same for purposes of issuing the permit apptied 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.
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Speclal Condltlons:
Permh Fee:
4l¿3.ra
Total Fees:
Ç 1¿3,o o
Fees Pald:
+ 123.aÒ
Bulldlng Permlt
ßLf.{F.11t5
OWTS Permlt:
5g?1,1116
lsgue Dete!Balance Due:+ø
Garfleld County Publlc Health Department!
Slgned Approval Date
09/06/2022