HomeMy WebLinkAboutApplicationGarfield County
� 195 W. 141h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
IA New Installation
BUILDING USAGE TYPE_ _
_® D_weiling I ❑ Transient Use
❑ Other Describe
INVOLVED PARTIES
❑ Alteration
❑ Comm./Industrial
Property owner: TA �" 1r' i cT4. l wj ��1n 11r d]fT►� �� { _Phone:
Mailing Add
Email Addre.
Contractor: . _ �� i S , t A4C_ Phone:
Mailing Address:
Email Address:
C
❑ Repair -
�❑ Non -Domestic
Mailing Address: ` b2b CV_ wc- •„C-O
Email Address: ie4,40 W .! LQ t tL 0 Yum W"e k
PROJECT LOCATION AND DESCRIPTION
Job Address: --1 i. -3 L` 1 7 [_ Tz_ 2_44;_ Ak_v r k �_-i 1_Z'��,� 1654-
Assessor's Parcel Number: ( Sub. Lot Block
Building or Service Type: Rc.� Ac."l Ace, #Bedrooms: Garbage Disposal(Y/N) _
Distance to Nearest Community Sewer System: it Ni
Was an effort made to connect to the Community Sewer System:
Potable Water Source 14 well ❑ Spring j ❑ Stream or Creek ❑ Cistern
& Type ❑ Community Water System Name
Garfield County Public Health Department — working to promote health and prevent disease
CERTIFICATION
I 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.
7 s'
Property Ow r Print and Sign D to
t )
OFFICIAL USE ONLY 123 C-91L 12-01V ow fo toZ(
Special Conditions:
Permit Fee.
t123.Q--*
Total Fees:
* tu-tol
Fees Paid:
1t3,ao
Building Permit
13MIE- G? 02.
OWTS Permit:
SEAT— 61d4
Issue Date:
0 - 1,
Balance Due:
4 -�-
Garfield CountyPublic Health Department: �
Signed Approval Date