HomeMy WebLinkAboutApplicationGarfield Coanty
Public Heulth
195 w. 14th Street
Rifle, CO 81650
(970) 52s-s200
2014 Blake Avenue
Glenwood Springs, CO 8160L
(970) 94s-66L4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New lnstallation E Major Repair E Minor Repair E Alteration tr Vault and Haul
BUILDING USAGE WPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
flother Describe ftrn
INVOTVED PARTIES
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Property
Email Address:
Mailing
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Mailing Address
Email Address:
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Was an effort made to connect to the Community Sewer System:
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Assessor's Parcel Nu
Email Address:
Sub. Lot Block
Distance to Nearest Community Sewer System:
Building or Service
PROJECT LOCATION AND DESCRIPTION
Job Address:
Mailing Address:
rbage Disposal(Y/N)- .A/-
21 Unr
prwett tr Spring E Stream or Creek E CisternPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional .rPo.n such further
nift;fi;na aaaitTonal tests and rdports as may be rbiuired by the local health derPartment to be
;il;;;t'f;iltirtr"O Uv tt'e applicant oi by the locdl health department for purpose of the evaluation of
iii" rppiii"tlon; Jna tlie issuiice of the. parmit is su.bject to sdch terms and conditions as deemed
neceis'arv to in!ure compliance with rulds and regulations made, information and reports submitted
il&iii.''r"d iequlrea t6 be submitted by the applicant are or will be rep.resented to be true and
toirect-io itrt Ueit of my knowledge and belief ind are designed to be relied on by the.local
Oepirtr"nt of heatth in'evaluatin[the same for purposes of issuing the. permit a.pplie.d for herein' I
ir1ittei unaeistand that any falsif'riation or misrepre3entation maylesult in the denial of the
lpiiication or revocation of any permit granted b'ased upon said ailplication and legal action for perjury
as provided by law.
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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 Owner Print and Sign Date
Special Conditions:
Fees Paid:ooTotal Fees:
( oo() .oC)
Permit Fee:(no @
Balance Due:lssue Date:OWTS Permit:3p.u-rsqsBuilding Permit
BLRE-*Sq cl
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
4/11/2024