HomeMy WebLinkAboutApplicationGurfield Coun$
Public Heulth
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81501
(970l.94s-66L4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New lnstallation tr Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
tr Dwelling E Transient Use ! Comm./lndustrial tr Non-Domestic
p Other Describe
INVOLVED PARTIES
Property one:t'ltotSt?-ddto
Mailing Address
Email Address:
7t qne (2to RTf/c tD 4 l6 so
L ,I k
t47n t {tY ?Ygq
Mailing Address 9a t1 I re
F
Email Address
II
(co t6a 3Mailing Address
Email Address:I f y4
PROJECT LOCATION AND DESCRIPTION
Job Address:
Assessor's ParcelNumbe r: e,tl tlobtM)6e
Building or Service type, AefTStW *yt gilWrA *Bedrooms: J Garbage Disposal(Y/N
Distance to Nearest Community Sewer System , N [ 4
na
Was an effort made to connect to the Community Sewer System:U4
Potable Water Source
& Type
;X wetr tr Spring E Stream or Creek E Cistern
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 maylesult 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 thq.Notice and Certification above as
well as have provided the required information which is correct and accurate to the best of
my kn
f,-/+ -au
and Sign Date
S-t\-a4Special Conditions:UerD Lw ao
Permit Fee:(rrYl@ '"'?'77., go Fees Paid:oo(nhO .
Building Permit
[4r0)? -K.aA OWTS Permit:<FFRA4 lssue Datel Balance Due:n
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
05/30/2024