HomeMy WebLinkAboutApplication-PendingGarfield County
Public Health
195 w. L4th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81501
(970) 94s-6614
OWTS PERM IT APPLICATION
E Minor Re trtr New lnstallation
TYPE OF SYSTEM CONSTRUCTION
tr rationtrMor E Vault and Haul
BUITDING USAGE TYPE
llhwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Propertyowner: filwr g S P" L^-Jer-t S oV Phone:
t
Mailing Address
Email Address:Ne +-
. A\oI
ne:
a
Email Address:
Mailing Address: lL
Contractor:
Sub. Lot Block
Was an effort made to connect to the Community Sewer System vl\ ts
Distance to Nearest Community Sewer System:5v,Q\or
PROJECT TOCATION AND DESCRIPTION
Building or Service Type Garbage Disposal(Y/N ldp-
Assessor's Parcel Number:
Job Address:
one: (
Mailing Address:
Email Address:
fg-antell E Spring E Stream or Creek E CisternPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
I CERTIFICATION
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 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.
Go*.rD. IJ.$r.nr -"n a,a$-
Property Owner Print and Date
;A Crp .t. E.N-L\
Special Conditions:
Permit Fee:Prv 9o
Total Fees:
.Crn P Fees Paid:
.trr'>@
NffE4,t(+a
OWTS Permit:
s,FFFq4<<
lssue Date:Balance Due:-h
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease