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195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 81501
(970l, 94s-66L4
OWTS PERMIT APPLICATION
Gurfield Coun$
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation tr Alteration tr Repair
BUILDING USAGE TYPE
El Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Own o \e (1.V- | 1o1- oGAT
MailingAddress: lGr-O ata ?.5 ar Rr.f,La C.p F:{t'VD
Email Address: Jave rurlh sr.njFe e r*';.rt, t,orn
hone:(9?r-r ) 1A1-oGbV
MailingAddress: lUa o aO e 5cr -Rl{le ( o 8(Lst>
Email Address:4 tt,! e f't\\ 5." ,+< e- Msr\. (o/^n
Engi z(t*o lLzS-Boo5
Mailing Address:
Email Address:
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PROJECT I.OCATION AND DESCRIPTION
Job Address:lLt- o ()t" AAq r?:"C\"r^ t4ri-,<r)
Assessorrs Parcel N umbe ri
-Sub.-Lot-Block
-Building or Service rvpe: S\fO ? / ADU *Bedrooms:-fGarbage Disposal(Y/N) \q
Distance to Nearest Community SewerSystem:3 '^ ,nnr\tS
Was an effort made to connect to the Community Sewer System : t.Jo
Potable Water Source
& Type
F well tr Spring E Stream orCreek E Cistern
El Community l rater System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application isconditional .uPo.n such further
r"r?iartow inO aAAitTonal tests and rdports as may.be rbluired by the local health department to be
ri j"i"O'fJrnisf'ea Uv ttte ipptrcant or by the locil heahh depardment for purpose of the evaluation of
i'tr"lppiiiution; Jna ttie issudrice of the p6rmit is su.bject to stich terms and conditions as deemed
n"i"isiw io iniure compliance with rulds and regu.laiions made,.information and.reports submitted
f'ei"*iti'rnl iiqulrea t6 be submitted by the -applicant are or ryill b.e rep.resented to be true and
torrect to itre Ueit of my knowledge and belief dnd are designed to be relied on by the.local
a"pJrtrint of heahh in'evaluatin[the same for purposes of issuing the permit a.pplie.d for herein. I
i*ittei ,nO"rstand that any falsifiiation or misrepre'sentation may result in the denial of the
lpdiiJition oirevocation 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.
4U - J,ooV/
Property Owner nt and Sign Date
OFFICIAT USE ONLY
Special Conditions:
Fee:oo Total Fees:(oOO oc)
I
Fees Paid:&
Buildi Permit
E-g
OWTS Permit:
bEPT-SSaq
lssue Date:Balance Due:AalT
Garfield County Public Health Department:
Signed Approval Date
03/11/2024