HomeMy WebLinkAboutApplicationGørfteld County
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
Puhlíc Heulth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L601
(9701945-6674
, TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration tr
BUITDING USAGE WPE
Dwelling tr Transient Use tr Comm./lndustrial lú Non-Domestic
flOther Describe
INVOLVED PARTIES
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Property
MailingAdd
EmailAddress:ì ,+ll.l.?'\
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Mailing Address:
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Engineer
MailingAddress:
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PROJECT TOCATION AND DESCRIPTION
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' Job Address:
, Assessor's Parcel Nu
Building or Service Ga rbage Dispos atlvßl ll-f
' Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source ;
tr Well n Spring fl Stream or Creek E €istern
Water System Name& Type
Garfíeld eounty Fublic Health Departm*nt * working tc prorrcte health anci prevent disease
Applicant acknowledges that the completeness of the application is.conditional.rPo.n such further
n'iándatory 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
neceisary to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tò be submitted by the applìcant are or will be rep.resented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the local
department of health in-evaluatíng the same for purposes of issuing the permit applied for herein. I
further understand that any falsifiıatíon 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.
CEANFrcATþN
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 Date
OTFICIAT USE ONLY
Special Conditions:
Total Fees:ao Fees Paid:CCPermit Feer
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lssue Date:Balance Due:-$.-owTsBuilding Permit
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Garfield County Public Health Department:
Signed Approval Date
05/03/2023