HomeMy WebLinkAboutApplicationGørfteld County
195 w. 14th street
Rifle, CO 81650
(e70) 62s-s200
Public lfeuhh
OWTS PERM IT APPLICATION
WPE OF SYSTEM CONSTRUCT¡ON
New lnstallation trRe tr
BUILDING USAGE TYPE
E Transient Use
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7ol94s-66r4
tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property
Mailing Address
Email Address:
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þ
Mailing Address:
Email Address:
PROJECT TOCATION AND DESCRIFnON
tr Alteration
Dwelling tr Comm./lndustrial
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Mailing Address:
Email Address:
Job Address:
Assessoy's Parcel â
Building or Service ,oor$ I narbage Disposal(Y/Nl-
Distance to Neerest Community SewerSystem:
Was an effort made to connect to the Community Sewer System
E Community Water System Name
tr Well tr Spring E Stream or creek þ cisternPotable Water Source
& Type
Garfield County Public Health Department - working to promote health 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 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 belíef 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.
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.
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Property Owner Print and Sign | 'o"t"
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Special Conditions:
Permit Fee:Total Fees:oolâå 'iåå,oo
lssue Date s.l":ÞBuildinc PermitBrX.aßrnî OWTS Permit:SPt-ßo\o
Garfield County Public Health Department:
Signed Approval DâtE
3/28/2023