HomeMy WebLinkAboutApplicationGørfield County
Public Health
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 8L601
(s7ol e4s-6674
OWTS PERMIT APPLICATION
BUIIDING USAGE TYPE
TYPE OF SYSTEM CONSTRUCTION
New lnstallation tr Alteration irtr
Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Property owner: S¿nlf 'Ydf¿no Phone: (11n I blY 7+'11
Mailing Address: Þ,rl , \; " )Ul*, 5, l'1, 4.0 g,lh 62I
"CoEmail Address:
contractor: OWl4€1"Phone: (_) Strr¡t+<
Mailing Address:
Email Address:
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S4¿trnÈ
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Engi Phone:
Mailing Address
Email Address:
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PROJECT LOCATTON AND DESCRTPTTON r
Job Address:
Assessor's Parcel Number:sub. G
Building or Service Bedrooms: -4 GarbageDisposal(Y/Nl-
Distance to Nearest Community SewerSystem
Was an effort made to connect to the Community Sewer System:v'ì^
Potable Water Source
& Type
tr Well ! Spring n Stream or Creek E Cistern
X Community Water System Name
Garfield County Public Health Department - working io promoie health and prevent disease
Applicant acknowledges that the completeness of the application is conditional .rpof. such further
nìdndatory 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
neceésary 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 misrepresentat¡on 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 and Sign Date
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Special Conditions:
'iää""'Fees Paid:0e\e3 L
Permit Fee @\àe I
lssue Date:BalanceBuilding Permit
bl*E"ØtÅ9,
OWTS Permit:
SEÞT. ßAR
Garfield County Public Health Department:
Signed Approval Date
05/04/2023