HomeMy WebLinkAboutApplicationRECEIVHN
G AftF lf; l.t] i;(.ii-iì{¡ I ?
c{)MÌYiU NITY Ùf:Vf : i-i iÈ'it'l ï : þì
195 W. L4th Street
Rifle, CO 8L650
(970) 62s-s200
Public Heølth
20L4 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-66r4
OWTS PERM IT APPLICATION TLtr
Gurfteld County
TYPE OF SYSTEM CONSTRUCTION
ED New lnstallation tr Alteration tr Repair
BUITDING USAGE TYPE
El Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner;ásfåfé øFgl@ßw,3Ç//¿n ¡t¿ê¿ <,tt- Phone:( "r-701 Ôlg-gg"ln
MailingAddress:Vê þt¿ ;?* 6l¿:f æ 8/6t9-
EmailAddress; Þh í1" h¿aÆ..cnty7.tí1" ¿:*rnnT
Contractor: Phone:
Mailing Address:
EmailAddress:
t* ¿rsrg (?1o | 3¿vl-€7{q
<t G fl-sMailing Address:/'h /,e*,t< til. CArIK¿aal ha tÃ' íø,
EmailAddress /-A2¿.11" (29'ri&*reØ ê- å ytnt ¿ " (cAn'l
PROJECf TOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel Num 9/ttr I
Building or Service Typez F&, #Bedrooms: { Garbage Disposal(Y/N)
^l
Distance to Nearest Commun¡ty SewerSystem
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
p wett E Spring E Stream or Creek E C¡stern
E Community Water System Name
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 knowledge.
'7L tslwl**,
Property Owner Print and Sign Date
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 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 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 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.
oFF¡crAt usE oNtY?aid
er¿ ¡þ lqq 4\âa.oo
Special Cond¡t¡ons:
Perm¡t Fee:
i ¡a ÕC,\,,J.^.-
Total Fees:
¡ ^(.t .'11^)Vl^ .*'-
Fees Paid:
t"tá "
crd
Buildine Permit
ßi trr-xår,,Q
OWTS Permit:
Sutr-"Mr"ß
lssue Date:Balance Due:
æ
Garfield County Public Health Department:
Signed Approval Date
03/09/2023
03/09/2023