HomeMy WebLinkAboutApplicationRECEIVED
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
Car eld County
�-�- 195 W. 141' Street Public Health2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
___
.- - _ _
New Installation ❑ Alteration I ❑ Repair
BUILDING USAGE TYPE _ —
14 Dwelling 10 Transient Use Y ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner:
Mailing Add
Email Addre
hone: (G76 f -2i14; - 3ga10
Phone: (47c)
Mailing Address: 1 7t C
Email Address: e G 4d '(c
Engineer:__- �z G 01 - -- — ---!! - Phone: (47b 1 5Nf - /an41
Mailing Address: If��,, 03mi 5!.ry SG, � atCe�d zl,, _
Email Address: gr4�r�fw gar
PROJECT LOCATION AND DESCRIPTION
Job Address: -
Assessor's Parcel Number: Sub. i t cg,� (sa�e��N Lot !_Block
Building or Service Type: lr-l., #Bedrooms: Garbage Disposal(Y/N) ;
Distance to Nearest Community Sewer5ystem:
Was an effort made to connect to the Community Sewer System:
Potable Water Source fit well ❑ Spring ❑Stream or Creek
& Type ❑ Community Water System Name
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 department to be F
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
i 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.
Property Owner Pr' and ign Dat
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
Total Fees:
fees�%alld: /� D d
Building Permit CWTS Permit:
Issue Date:
061, V
Balapce Due-
L"t
Health Department:��✓
Garfield county Public M ea
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Signed Approval
Date
1'a2c'� of
I ndate,I Dec M