HomeMy WebLinkAboutApplicationRËCEIVED
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195 W. 14th Street
Rifle, CO 81650
(s70) 62s-s200
Public Heølth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970194s-6614
i wÈr or svsrrrvltorufrducriou
tr New lnstallation E Alteration & Repair
BUILDING USAGE TYPE
Dwellíng U Transient Use tr Comm./lndustrial Ü Non-Domestic
Property +f
Mailing Address
Êmail Address:
Mailing Address:
Email Address:
PROJECT TOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel sub.-rot-Block
-BuildingorService tVpetReþcd¿s,'*tA-9 *Bedroomsr I GarbageDisposal(Y/N] t
Distance to N ea rest Com m u n ity Sewer System : LJ-4J¿-{n. OIAfl^-
Was an effort made to connect to the Community Sewer System;ula
Potable Water Source
& Type E Community Water System Name
Gørfield County
flOther Describe
Lr c
Nl
qao þt
Mailing Address:
Email Address:
Phone: (q1ct vú'585c'r¡)/l A ()41¡r to,
n C¡sternpweuE Spring El Stream or Creek
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application isconditional .upo!", such further
nia'ndatory and additional tests and reports as may be required by the local health department to be
made and'furnished by the applícant or by the local health department for.purpose of the evaluation of
the application; and tl"ie issuánce of the pòrmit is subject to such terms and conditions as deemed
neceisary to iniure compliance with rules and regulations made, information and.reports submitted
herewith'and required tò be submitted by the apþlicant are or will be represented to be true and
correct to the belt 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 apRlie.d lor herein. I
fulther understand that any falsifiéation 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
well as have provided the required information which is correct and accurate to the best of
my
Pri Date
z
OFFICIAL USE ONIY s\ål=ìô
Speciâl Cond¡tions:
Total Fees:aôs?5Fees PaidoÕPermit Fee:ønç.
Balance Due:lssue Dãte:Building Permit OWTS Perm¡t:
Lgôb
Garfield County Publ¡c Health Department:
Signed Approval Date
10/31/2022
$75.00
11/01/2022 $0.00N/A