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L95 W. 14th Street
Rifle, CO 81650
(970\ 62s-s200
Puhlic Heslth
OWTS PERMIT APPUCATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(97Ols4s-6614
Gaffield County
WPE OF SYSTEM CONSTRUCflON
New lnstallation tr Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
S Dwelling I Transient Use n Comm./lndustrial fl Non-Domestic
E Other Describe
INVOTVED PARTIES
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PROJECT LOCATION AND DESCRIPTION
Was an effort made to connect to the Community Sewer System:
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Distance to Nearest Community Sewer System:
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Garfield Counly 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 additional tests.and reports.as may be rbquired by the local health department to be
made and furnished Qy tfre 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 cohditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submittedherewith and require_d to be submitted by the applicant are or will be represented td 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 apptleO for herein. Ifurther understand that any falsification or misrepresentation may result in the dehial of the
application.or revocation of any permit granted based upon said af plication and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as
wellas have provided the information which is correct and accurate to the best of
my knowledge.
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Property Owner Print and Sign Date
OFFICIAT USE ONLY %.la c-v-r{-Lt-aq
Special Conditions:
Permit Fee:boo9c,Total Fees:
toOO oe Fees Paid:@(a@.
Building Permit
Ru08(sqq
OWTS Permit:
SEPr-?fuoc:
lssue Date:Balance Due:
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Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promole health and prevent disease
04/24/2024