HomeMy WebLinkAboutApplication-PendingGarfield County
1"95 w. 14th street
Rifle, CO 81.650
(970) 52s-s200
Public Health
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(e70) e4s-6614
TYPE OF SYSTEM CONSTRUfiION
tr New lnstallation E Major Repair 88, Minor Repair E Alteration tr Vault and Haul
BUILDING USAGE TYPE
B Dwelling E Transient Use n Cornm,/lndustrial tr Non-Domestic
E Other Desgibe
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nddress;F-0. &GrF t +6 (vtepoAoeuS-,*-4 (,b:r-3
ri* @- sa+r4s o n*-J-Email Addressr
Phoner
Property
Mailing
Mailing Address:
Email Address:
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Mailing Address:
Email Address
PROJECT I.OCATION AND DESCRIPTION
Assessor's Parcel Number:-Sub,-lot-Block
-
Building or Service fyper 5FA fBedrooms:- S-- -. Garbage Disposal(Y/N) Y
Was an effort made to connect to the Community Sewer System:r.\e>
Distance to Nearest Community Sewer System:) fl fue-t
Job Address: A'?g L a-a
El-Well E Spring E Stream or creekPotable Water Source
& Type
E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges thatthe 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 locdl health departhent for purpose of the evaluation of
the applicationl and the issuance of the permit is subject to such terrns and conditions as deemed
necessary to.insure compl.iance with rules and regulations made, information and reports submitted
herewith and required to he suhmitted hy 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 apptieU for herein, I
further understand that anyfalsification or misrepresentation rnay result in the dehial of the
application.or revocation of any permit granted based upon said afrplication 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.
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Property Owner Print and
Special Conditions:
'ffi"oo Total Feesl oE)-b-tO.
Fees Paid:tu g(>r
Permit OWTS Permit:3p.r-84q?lssu€ Date:Balance Due:a
Garfield County Public Health Department:
Signed Apptroval Dato
Garfield Coun$ Public Health Department -working to promote health and prevent disease