HomeMy WebLinkAboutApplicationGARFIELD COUNTY
Co¡,ttrt uutrY DEV E LoP MËNT
REGEIVED
1-95 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Heølth
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970) 94s-66L4
OWTS PERMIT APPLICATION
Gørfield County
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration tr Repair
BUITDING USAGE TYPE
El Dwelling U Transient Use tr Comm./lndustrial tr Non-Domestic
tr Other Describe
INVOTVED PARTIES ,
Property e:
Mailing Address
Email Address:a
one:
Mailing Address:
EmailAddress:
tl
t
Mailing Address:
Email Address:
PROJECT IOCATION AND DESCRIPTIOI\¡
Job Address:
Assessor's Parcel N 2tL731zoc:3t3 S
^
Lot 'L[ glocr
-4
t'ayã.L
Building or Service Type: Ffo m < #Bed A Ls)Disposal(Y/N)_
Distance to Nearest Community SewerSystem:
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
tr Well tr Spring E Stream or Creek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional .upo¡ such further
nìa'ndatory and addii'ronal tests and rdports as may be required by the local health department to be
made andîurnished by the applicant or by the locál health depariment for purpose of the evaluation of
the application; and tlie issuáñce of the pèrmit is subject to such terms and conditions as deemed
neceisãrv to iniure compliance with rulés 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 beit 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 applie.d for herein. I
further understand that any falsifiıation or misrepresentation may result in the denial of the
application or revocation of any permit granted b-ased 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
knowledge.
Property nt and Date
oFFlclAL USE ONIY pl..g $ -t5.ocl e. c.o1 /" o I z-ozz- éþ^
Spec¡al Cond¡tionsr
Perm¡t Fee:
.+ 71. oo
Total Fees:
$ 7t. oo Fees Paid
$ 75. a"'
Building Permit
BLR9-183G
OWTS Permit:
SÊ"T .1 E 31
lssue Date:Balance Due:+d
Garfield County Public Health Department
Signed Approval Date
11/1/2022
11/01/2022