HomeMy WebLinkAboutApplicationl"(tr UrlVh,¡_¡
GARFIËLD çOUNTY
COMMUNITY DEVELOPMENT
Public Heølth
L95 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
201-4 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERM IT APPLICATION
Garfteld County
TYPE OF SYSTEM CONSTRUCTION
New lnstallation tr Alteration tr Repair
BUILDING USAGE TYPE
þ Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
tr Other Describe
INVOTVED PARTIES ,LQ\Ihone:
0
@
Property
Mailing Address:
Email Address:
Phonea
Mailing Address:
Email Address:
Enginee
Mailing Address:
EmailAddress:
PROJECT TOCATION AND DESCRIPTION r
Was an effort made to connecyo the Community Sewer System3
\
Distance to Nearest Commun¡ty SewerSystem:
Block
rbage Disposal(Y/N)-
Job Address:
Assessol's Parcel N
Building or Service
E Stream or Creek E Cisternt/well tr Spring
E CommunityWaterSystem Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
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
lo- Zo -27
Owner Sign Date
Applicant acknowledges that the completeness of the application isconditional.!Po.n such further
m-a,i¿ãtory ãn¿ ad¿¡i¡onal tests and rdports as may.be r'equired by the local health department to be
rãà"ãñ¿'trrnisñà¿ by the applicant or by the locál healtñ depariment for.purpo.se of the evaluation of
itrã appìið"tìon; and tlíe issuáñce of the pêrmit is su.bject to súch terms and conditions as deemed
necejsãrv to inlure compliance with rulés and regulaiions made, information and reports submitted
frãið*¡it''an¿ iequired tò be submitted by the applìcant are or will be rep.resented to be true and
còrrect to the beit of my knowledge and belief and are designed to be relied on by the.local
ããpãrtment of health in'evaluatin[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
àpıiiðátión óirévocation of any permit granted based upon said ápplication and legal action for perjury
as provided by law.
sOFFICIAL USE ONLY oô
Special Conditions:I
Paid:oôFees$ld'rä.*Fee:oô
lssue Date "'s'6"boOWTS Perm¡t:3flrr-787-GBuilding Permit-7Æ1
Garfield County Publlc Health Department:
Signed Approval Dete
11/10/2022
11/10/2022