HomeMy WebLinkAboutApplication-Pendingr[B * $ ,lr]irq
195 W. t4th Street
Rifle, CO 81650
(e70) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
{e70l.e45-56L4
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCflON
tr New lnstallation
BUILDING USAGE WPE
tr- D*;tii^; -
l-E Transient Use
tr tr Minor tr on
tr rial tr Non-Domestic
ElOther Describe
Garfield County
INVOLVED PARTIES
Property ne: (-4i;| 491 otq 5
Mailing naaress: lb{ Suwr.A- AOrt-- €D AF+-, to t{c*e
Email Address:
Mailing Address:
EmailAddress:
one: ( )
Mailing Address:
EmailAddress:
EI Sprlng
PROJECT TOCATION AND DESCRIPTION
Job Address:
"i;t{-^
<.-p'Dfi.L 2.n r a 7 tt-4l,
Assessorr's Parcel Nu 1-r't-1
Building orService Type. 6 $'yP #Bedrooms: 2 Garbage Disposal(Y/NLrJ--
Distance to Nearest Community Sewer System:.nrAr
Was an effort made to connect to the Community Sewer System:M*
Potable Water Source tr Well El stream or Creek K clstern
& Type D Community Water System Name
CERTIFICATION
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 applicationl 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 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 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
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Owner Print and Sign drt.
OFFICIAL USE
/v-FT-+gu+ \rSpecial Condltions:
Total Fees:
Acr-t oo PBb.ooPe5cfi e"
OWTS Permlt:c'EPI-f,34L lssue Datsl Balance Due:
flilitr
Slgned Approval
Garfleld County Publlc Health D€partmenti
I
Date