HomeMy WebLinkAboutApplicationri
1,-'1.
GAt,(r.¡¿;i"u
COMMUNITY I]E
Lt¿r-¡¡ri ¡.Y
Public Heulth
195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 8L601
(9701945-6674
OWTS PERM IT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCÍION
t New lnstallation E Major Repair E Minor Repair El Alteration E Vault and Haul
BUILDING USAGE TYPE
E Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
EIOther Describe
INVOTVED PARTIES .
Property
Mailing tØl
Email Address:rn,r*..t?4 @.d.rn^\[ , Aørr,
I
Mailing Address:
Email Address:
Engi
Mailing Address:
Email Address:lnAr ¡^ ri<|Qþ:Lê t6r, 6.I\.4rtl (o*,
PROJECT TOCATION AND DESCRIPTION
Job Address:
Assessor's Pa rce I N u mbe r : AR I L47.b o21 fsub.-tot-Block
-BuildingorServiceType:#Bedrooms:-GarbageDisposal(Y/N)-
Distance to Nearest Community Sewer Systemi
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
I Well tr Spring E Stream or Creek E Cistern
E Community Water System Name
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
ttiãnaJtory and addiiional tests and rdports as may be required by the local health de_partment to be
mã¿ã ànA'trrnished by the applicant oi by the locál health department for purpose of the evaluation of
the application; and ttie issuånce of the pôrmit is su.bject to such terms and conditions as deemed
ñ"ãéËs'aw to iniure compliance with rulés and regulaiions made,.information and.reports submitted
herew¡th'and required tò be submitted by the apþlicant are or will be rep.resented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatin[ the same for purposes of issuing the permit applied lor herein. I
turiher understand that any falsifiıation or misrepre-sentation may result in the denial of the
application or revocation of any permit granted bàsed 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.
.".7 ,/,aá,*e/,ä Ø-zl -.Åa23
Property Owner Print and Sign Date
FOFFICIAT USE ONLY I
Special Conditions:
(,oFees Paid:
laÕO
Total Fees:ooLoæ¡t Fee:co
a
Balance Due:lssue Date:OWTS Permit:
æT-qÐ(nABuilding Permit
Signed Approval
Garfield County Public Health Department:
Date
Garfield County Public Health Department - working to promote health and prevent disease
08/31/2023