HomeMy WebLinkAboutApplication-Pending:'i:. r:'.i ',i ,i,
iti i ' 'r -r I )
i.: r. i'. ;- :...;,.-: .t '-, i' : I
i. i-ii:ii,il l.':, i'," ri'\ii:i -1ri:;
195 W. 14th Street
Rifle, CO 81650
(970) 52s-s200
Public Health
OWTS PERMIT APPLICATION
20L4 Blake Avenue
Glenwood Springs, CO 8L501
(970)94s-661,4
Garfield Coun$
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation E Major Repair E Minor Repair ELAlteration E Vault and Haul
BUILDING USAGE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
F ottrer Descr:ibe
INVOTVED PARTIES
0 t@b
L
Property t"I LU I A bV -l-D> U
50Mailing Address
Email Address
(
Mailing Address:
Email Address:
Email Addressi
WasaneffortmadetoconnecttotheCommunitySewerSystem:
()
DESCRIPTION
0@
Disposal(Y/N)_
Assessor's Parcel Num 1
Distance to Nearest Community Sewer System:
Building or Service Type
Mailing Address:
Engineer:
Job Address:
PROJECT IOCA
tr Well E Spring E Stream or Creek E Cistern
Community Water System Name O
Potable Water Source
& Type
Garfield County Public Health Department -working to promote health and prevent disease
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.
lo &J5
Property Owner Print and Sign Date
Special Conditions:
,U[fr OO ,"H;;h
,OO '*'Atnoo
Buildins Permit
w I \7-Q{AA
OWTS Permit:c-wrq<eLl lssue Date:Balance Due:o
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease