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L95 W. 14th Street
Rifle, CO 81650
(e70) 62s-s200
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 8L601
(s70l.94s-66L4
OWTS PE RM IT APPLICATION
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Gurfield County
TYPE OF SYSTEM CONSTRUCTION
E ruew lnstallation E Major Repair E Minor Repair E Alteration EI Vault and Haul
BUILDING USAGE TYPE
p Dwelling E Transient Use E Comm./lndustrial tr Non-Domestic
E Other Describe
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Email Address:
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Email Address:
PROJECT TOCATION AND DESCRIPTION I
Assessor's Parcel Number: J 31 53 69Oot5&ub.-tot-Block-
Was an effort made to connect to the Community Sewer System:
Job Address:6äì
Garbage Disposal(Y/N LLt
À,Distance to Nearest Community Sewer
,Vo
Building or Service
E CisternH well tr Spring E Stream or Creek
E Community Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additionaltests 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
necessaryto 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 anyfalsification or misrepresentation may result in the denialof 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 Not¡ce 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 l^t"''
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OFFICIAL USE ONLY
Special Cond¡tions:
'*7";:ä.,,col Total Fees:ooGcn Fees Paid:
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&uildins Permit I OWTS Perm¡t:
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lssue Date:BalanclP_ue:
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Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
07/10/2023
07/10/2023