HomeMy WebLinkAboutApplicationGaffield County
Public Heølth
195 w. l-4th street
Rifle, CO 81-650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-661"4
OWTS PERM IT APPLICATION
TVPJ OF SYSTEM CONSTRUCT¡ON
New lnstallation tr Alteration n Repair
BUTÐING USAGE TYPE
Ef Dwelling E Transient Use ! Comm./lndustrial tr Non-Domestic
fl Other Describe
INVOLVED PARTIES
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Property Owner
EmailAddress:
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Contractor Phone: (4lO) Z161 -4Zor:.
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EmailAddress:
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Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
Assessor,s parcetNumb "rt%1 1931AøZ-^ub. Nóù,LF- Lot_Btock
Was an effort made to connect to the Community Sewer System
Job Address:
Garbage Disposal(Y/NBuilding or Service Type:?&t #Bedrooms: 6
Distance to Nearest Community SewerSystem:
! Stream or Creek ! Cisternfl wetl [J Spring
E Community Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
Anolicant acknowledges that the completeness of the application isconditional upon such furth.er
;Ëüåäå;;n¡-ffiifi,;ilíi.ìiïã'ìù rdporrsås may.þe rbi¡ulred bythe.localhealth departmentto be
;ffiä;îå'r;;;irñäïi iT" ãóîrrcä-'i ãi ¡v u,ã iäãålj'"åittr ¿*parúment for.purpo.se of the evaluation of
lü:ipäË;ü;;;il iti.'i;;liíricäói irre pärmit is iu¡jeit to süch tenns and'coñdltions as deemed
necessary to insure *rnüií.iääritil'irilåJana *ie,'tãtioñi màde, information and.reports submitted
ü;;;;üi,'r';d';"ıt'lr;ä tåä';r"#ìilä'Ëi iüã a"üìããni arà or '¡i¡lt ue reoresented tó be true and
correct ro rhe best orn'ir,,i*lääää;;i'bàliãi;'iJãiä ¿"rieÏeã io ue reliea on by the.local
deoartment of heatth ¡nLiäÏ,iåäñc'irtì Juãið ror purposes oÏ issuing the permit qpplje.d lor herein, I
i,trñli;iå;;;täiäîËåi;;; f'l;iii;'iiınôr nr¡ire'preientation mayiesult in the denial of the
aootication or revocarion'äi;;; pãimir b;árt"d
-uásea upon saicl application and legal action for perjury
ai þrovided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the required informatlon which is correct and accurate to the best of
my
Propefty owner Pr¡nt and s¡gn
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Speclal Condltlonsl
FeesPa¡d: tÞ?.æFeês:
.ootee:
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Balance Due:
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lssu€ Date:oWTS Permlt:Building Permit
Garfield County Public Health Department:
Signed APProvel
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Date