HomeMy WebLinkAboutApplication-PendingDocusign Envelope lD: 1 750D3EB-3878-4DOA-8C5A-59838084DE2E
195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
l970l94s-66L4
OWTS PERMIT APPUCATION
WPE OF SYSTEM CONSTRUCTION
F[ r,rew ingiatliiion l_n rtlta.;or Repair I n Minor Repaii I - Alteiaiion i n vauit ind Haul
I
BUILDING USAGE WPE
F Dwelling
D Other Describe
E Transient Use l- comm.ftndustrial ln Non-Doryrestic
Gorfield County
INVOTVED PARTIES
Property Owner:
Mailing Address:
EmailAddress:
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Mailing Address:
EmailAddress:
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Phone:
Mailing Address:
EmailAddress:
PROJECT TOCATION AND DESCRIPTION
Job Address:n1q wt-b [A/ r Tlr.4;l+, C0 8'l usa
,Agwt1Assesso/s Parcel N
Building or Service
& Type
Disposal(Y/N)-NO
Distance to Nearest Community Sewer System:NA
Community Sewer System:no
O Sprlng E Streamorcreek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Docusign Envelope lD: 1 750D3EB-3B7B4DOA-8C5A-5983808ADE2E
CERTIFICATION
I hereby acknowledge that I haye read and understand the Notice and Certlflcatlon above as
well as have provided the required informatlon which ls correct and accurate to the best of
chi p suthe"P;fnowledse'
Dcuslgnod by:3/2s/202s
PropefiOwner Print Date
Aoolicant acknowledges that the completeness of the application isconditional.uPol such further
;i.;;;;il;iil-idait?"nat tesii and rdports as may be rbiuired by the local health de-partment to be
ffiffift'f;ilr-h;-6t'ihe ap-pticint o.i trytne locilhealtli depart'ment for purpo.se of the evaluation of
i'dl *"iiijtiou Jni itie issuirice of the pbrmit is subject to such terms and conditions as deemed
;;;;fi; il liiiri. .limpliiniJwith rulds and regulaiions made, information and.reports submitted
il;;ilTit'a;d ieqi,ared tJ be submitted by the applicant are or will be represented to be true and
;;;ftil 6 ih; Ud;i oi mv knowledge and'belief ind are designed to be relied on by the.local
ii'dJn-"i"":i of neilitt in'evaluarinfthe same for purposes of issuing the.permit a.pplie.d for herein' I
i;ti[;;;;A;istjnJitrai iny falsiftiation or misre'pre-sentation may result in the denial of the
looii.ltion or revocation of anv permit granted bbsed upon said aiplication and legal action for perjury
ai'provided by law.
oFFrcrAt usE ot{tY
Speclal Condhions:
ooPald:Totel Fees:oe,)Fee:oo
lssue Datc:Eulldlng Permlt
Garlleld County Public Heahh Departm€nt:
SlgnedApproval Date
Garfield County Pubtic Health Department - working to promote health and prevent disease