HomeMy WebLinkAboutApplication - PendingGurfteld County
195 w. 14th Street
Rifle, CO 81650
(e70) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
TYPE OF sYsTEM CONSTRUCTION
New lnstallation [J nnajor Repair
Mailing Address:L u 6rGo
EmailAddress: D€-LV e Bcl-tpL.
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970194s-661.4
I Minor Repair D Alteration n Vault and Haul
I Transient Use
BUITDING USAGE TYPE
Dwelling n Comm./lndustrial Non-Domestictr
I Other Describe
L
Email Address:Ton, ba:\ftt-v+1 70 (- CutOlu $ S f n4c
Property
Mailing Address: CL4
INVOTVED PARTIES
6 ,5.t
Mailing Address
Email Address:
L oOt)L3 Ao
PROIECT TOCATION AND DESCRIPNON
Job Address:
Assessor's parcetNumb "rWua. kS G*Lb ,*:fu-uo"rl7u{[4 3
Buildingorservice tvp", 5 FL *Bedrooms:I Disposat{Y/Nl-Y-.
Distance to Nearest Community Sewer System:tut 5
Was an effort made to connect to the Community Sewer System:,t/o
(wel [1 Spring fl CisternPotable WaterSource
& Type E Community Water System Name
I Stream or Creek
Garfield County Public Health Department -- working to promote health and prevent disease
CERTIfICAT{ON
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 any falsification or misrepresentation may result in the denial of 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.
Epnlusro Ct-r'-*-* C*-/a.b,?5
Property Owner Print and Sign Date
OFFICIALUSE ONLY 00
Special Conditions:tJ
Pgrmit Fee: *-.
( dY: ,''*Fees:
C)f1CC
Total
G
Fees Paid:
( ofi},00
Buildine Permitg$iErtf.38 OWTS Permit: ^sl=[ff-(/rfir)
lssue Date:Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease