HomeMy WebLinkAboutApplication-PendingAZGarfield County
195 W.14"Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-%14
DINTS PERMIT APPLICATION
TY OF SYSTEM CONSTRUCTION
New Installation ' ❑ Major Repair ❑ Minor Repair ❑ Alteration ❑ Vault and Haul
B OING USAGE TYPE
Dwelling I ❑ Transient Use ❑ Comm./Industrial _ ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
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Property Owner:
Phone:1[
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MallingAddress:
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Email Address:
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Contractor:hone:(
Mailing Address:
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Email Address:
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Engineer: (;}
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_ Phone: 97a
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Malling Address:
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EmallAddress:
PROJECT LOCATION
Job Address:
Assessor's Parcel Number:. V 39 � I81010 +ub. �] 01-eJrr Urn' - lot Black
Building or Service Type: AUMOOMTIe;6#1V,,=4edrooms: Garbage Disposal(Y/9�_
Distance to Nearest Community Sewer System: N ■ A
Was an effort made to connect tyhe Community Sewer System:
Potable Water Source all ❑ Spring ❑ Stream or Creek
& Type ❑ Community Water System Name
❑ CWem
Garfield County Public Health Department — working to promote health and prevent disease
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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 de artment to be
made and furnished by the applicant or by the local health department far purpose ot�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 appiied 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.
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Property Owner rint and Sign
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Date
OFFICIAL USE ONLYA L
Special Conditions:
Permit Fee: O O
Total Fees: CO
Fees Paid: 00
Building Permit
OWTS ermit:
Issue Date:
Balance Due:
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Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department — working to promote health and prevent disease