HomeMy WebLinkAboutApplication-PendingGarfreld C*wrrty
Ssd$$$c Nssw$s$w195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
20L4 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-661.4
OWTS PERMIT AP PLICATION
TYPE OF SYSTEM CONSTRUCTION
New lnstallation n Major IT ! Minor Repair I Alteration E Vault and Haul
ILDING USAGE WPE
Dwelli n Transient Use n Comm./lndustrial tl Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Address
Email Address:
e:
o
,ne
Mailing Address
Email Address:
Engineer:_l
Mailing Address
Email Address:
PROJECT TOCATION AND DESCRIPTION
Was an effort made to connect to the Community Sewer System:
ZrL 9ot
Disposal(Y/Ni NA
Lot_ Block
Job Address:
Assesso/s Parcel Number
Building or Service
Distance to Nearest Community Sewer System:
Well tr Spring E Stream or Creek n cisternPotable Water Source
& Type I Community Water System Name
SnrlieleJ ***n{y Fubli* Fl*alth **pnrtr**nt * warking t* pr*m*t* hsalth **d prevent dis**s*
Applica.nt acknowledges that the completeness of the application is conditional upon such furthermandatory-and additional tests.and reports,as may !e required by the local health department to bemade and furnished by the applicantai by the locilhealt6 oepa*lnent i;iil;G; "Tti* evatuation ofthe aBBtication; and the issuance of the pbrmit is subject to such terms and'co;;itil;;; deemed
l!cess.:.ry toinsure compliance.with rules and regulaiions made, information-;"d ;;p;itr suUmitiedherewith and required ts.be submittod by the -applicant are or wilt Ue ,epi"runt"U t-j6e true anOcorrect to the best of my knowledge.and belief ind are designed to ue i*tj*d ;n uvlr'i jocar
departnrent of health in evaluatilg the same for purposes o? iilui"slh;;;;ii'Jp'oii"i ?"r herein, Ifurther understand that any falsifiiation or misrepreieniation'miv?rii"tiiiigt" iliir-rli1,-application.or revscation oi any permit granted bbsed upon saia ibptiiaiil; ;ft6;;j riiion to, perjuryas provided by law.
I hereby acknuwledge that I have read and undsrstand the nlotice and Csrtificatlon abnve as
well as have provid*d the reguired information which is correct and accuratc to the best of
my kn
and Sign Sate
Special Conditionsr
It Feel oc ,OQ
Fees:Fees Paid ao
l*rue $ate:B*larce Dugr
Garlield County Fublic Heahh Department:
Signed Approval Date
Snrfield C*unty Fublic I'i**fth il*partm**t * working ts prcfist* he*lth and pr*v*nt dise*se