HomeMy WebLinkAboutApplicationGarfield County
195 w. 14th street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L501,
(970) s4s-6614
TYPE OF SYSTEM CONSTRUCTION
t New lnstallation tr Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES ,.r''
Property ne:t V'Vlt C /7 ' Q' r' 7&/
Mailing
EmailAdd n4
Contractor el
Mailing Address:
Email Address:
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e:
Mailing Address:*a €t
Email Address:
Job Address:4
Assessor's m 4 Lot 7 Block---r-
Building or Service Type Ga rbage Disposa|(Y@-
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:.4/n
Potable Water Source
& Type
fl wetr tr Spring E Stream or Creek E Cistern
E Community Water System Name
PROJECT TOCATION AND DESCRIPTION
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the appllcatlon ls condltlonal 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
necessaryto 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 anyfalsification or misrepresentation may result in the denialof 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
my knowledge
3*lo -AS
Property Owner Pri and Sign Date
Special Conditions:
'[H5po ooTotal Fees:la Fees Paid:(o@,6d
Buildins PermitRmp-qnl OWTS-Permit:ffiqtaa lssue Date:Bala Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department-working to promote health and prevent disease
03/20/2025