HomeMy WebLinkAboutApplicationRECEIVED
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i-95 w. L4th street
Rifle, CO 81650
(970) 62s-s200
201-4 Blake Avenue
Glenwood Springs, CO 8L601
(970) 94s-6614
OWTS PERM IT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUC-NON
p ltew lnstallation D Major Repair E Minor Repair D Alteration E Vault and Haul
BUITDING USAGE TYPE
I Dwelling El Transient Use tl Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
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Email Address:
Mailing
Email Address:
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Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
Building or service rvp", t\d lfl € *Bedrooms: 3 Garbage
Was an effort made to connect to the Community Sewer System
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Assessol's Parcel Number: Sub.
Job Address:
Distance to Nearest Community Sewer System:
E Stream or Creek E Cisterntr well E Spring
p Communiry Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is.conditional upon such further
niandatory and addit'ronal tests and rdports as may. be required by the local health dorlartment to be
made and furnished by the applicant oi by the local health department for purpose of the evaluation of
the application; and tlie issuince of the. permit is su.bject to such terms and conditions as deemed
neceis'ary to insure compliance with rulds and regulations made,-information and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be rep.resented to be true and
correct to the be'st 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.
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
knowledge.
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Owner Print and Sign Date
\OFFICIAT USE ONIY
Special Conditions:
Fees Paid:OO(eOO,,@booTotal Fees:Permit Fee:go
lssue Date:Balance Due:o-'OWTS Permit:
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Building Permit
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Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
08/02/2024
08/02/2024