HomeMy WebLinkAboutApplicationGørfield County
Fss{t{ic Hes[tls195 W. 14,h Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
l970l94s-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
E Alteration E Repair
BUILDING USAGETYPE
P( owelt¡ne E Transient Use El Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
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PSOJEçT IOCATION AND OESCRIPTION
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A¡se¡sor,s parcet Numbe ,,27.11:TrÊJ-r-LíL suuLøþ:5e lÅM.t-t bt 5? elr,ck _
Sullding or Service Ça^D¡sposal{Y/N}-l-
Dlstance to Nearest Community SewerSystem:t .,-15 t\,*-Ç-*
Was an effo¡t made to connect to the Communlty Sewer System:ì.,1D
Potablewatersource lf Well [J Sprinß ff StreamorCrcck f]l Clstern Münnf.f
& Type (Community Wâter Syrtem Name
Garfield County Public Healtlr Departrnent - working to promote heallh and prevent disease
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 locaf 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 condit¡ons as deemed
necessary to ¡nsure complíance with rules and regulatíons made, informatíon 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 oi issuing the permit applied for herein. I
further understand that any falsifiiation or misrepresentation may result in the denía-l of the
application or revocation of any permit granted based upon said ;ipplication and legal action for perjury
as provided by faw.
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as
which is correct and accurate to the best of
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Property Owner Print and Sign Date
wellas have provided
mv knowledee.Ggi'tvoÊ\'r¿tt
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OFFICIAL USE ONIY +¿l ,oo
Sgc<Ìal Cond¡t¡ont:
Permlt Fee:lI!'oo
Total Fees:gl.oo Fees
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Paid:OG2
Bullding Permit
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l¡Jue Dete:Ealance Dl¡c:+
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Slgned Approval Date
03/20/2023