HomeMy WebLinkAboutApplicationGarfield County
Public Health195 W. 14`h Street 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUcnON
❑ New Installation ❑ Alteration Repair
BUILDING USAGE TYPE
0- Dwelling ❑ Transient Use ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARnEs
Property Owner.
Mailing Address: 7
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2. Sor-iPL3
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Phone: (Cy! t7
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Email Address: r
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Contractor: C'f e Ski
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Phone: (�>7�� - 7
Mailing Address: 7
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Email Address:
Engineer.
Phone: f i
Malting Address:
Email Address:
PROJKT LOCATM AND
Job Address: :z q_3
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Assessor's Parcel Num#ser:ffJJ ��f �/ 5� �Z Black
Building or Service type: "�� G f��"�f NBedroorns: Garbage DisposatLY/N) p�
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Distance to Nearest Community Sewef System: �� 9c31�
Was an effort made to connect to the Community Sewer System: ��
p crwiTff : ❑ stream or creek
Potable Water Source! ^ "'a"
& TVPe ❑ Community Water System Name
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Garfield County Public Health Department -- working to promote health and prevent disease
CERTIFICATION
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 clef as
to be of
made and furnished by the applicant or by the local h lth epl termsent and for pond t onus deemedhe attlonpermitthe application; and the issuance of the permIs s 1e
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. 1
further understand that any falsification permit ogranted based ed upon said aresentation pplication cationresult in the and legal lof the
s action for perjury
application or revocation of any p
as provided by law.
t 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.
perry Owner Print and Sign Hate
OFFICIAL USE ONLY :P6 !t is °° CC 0
Spedal Conditions:
Total Fee* * -7 S.
es Paid-.
permit Fee: *IT- �
4 Z ! • Issue Date: Balance Due:
sulldlnj Permit owTS Pernik: y
N h
� 1
� . z(
.,rFi,4d County runlet Health Department: Date
516ned Approval
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