HomeMy WebLinkAboutApplication4
Public Health
195 w. L4'h street
Rifle, CO 81650
(e70)62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601-
pTAle4s-661.4
OWTS PERMIT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
New lnstallation tr Alteration tr Repair
BUITDING USAGE WPE
){ Dwelling EI Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
IT{VOIVED PARTIES
I
Property
Mailing Address
Email Address:
l- cD 8l
Mailing Address:
Email Address:
Engineer: A/tlefr'cart 6ca3ctUr'ee,3 Phone:
738 Svtll/rc,Avo,. tvtilttt>to,r* ca g613)-MailingAddress:,(I
Email Address:
PROJECT TOCATION AND DESCRIPTION2;l C6up'Lu Pa,.,J 227- Kitrle- Ca ,lIAiA
Distance to Nearest Community SewerSystem, NIA
Was an effort made to connect to the Community Sewer System:
Job Address:
a
Building or Service
Block
l1
Disposal(Y/Nl N
Assessor's parcet Numb .r,2 D? [4007? tl su
Kwel E 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 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 application; 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.
trRTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provlded the reguired information which is correct and accurate to the best of
my knowledge.
Property Owner Print and Sign Date
t 2
OFFICIAT USE ONLY
Special Condltions:
Fe€:@o Total Fees:oo Fees Pald:oo
Permit OWTS Parmlt;lssue Date:Balance Due:
Garfield County Public Health Department:
Signed Approval Dete
5/2/2024