HomeMy WebLinkAboutApplicationGarfield County
195 W. l4t�' Street IqlINEW Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-6614
OWTS PERMIT APPLICATION
TYP OF SYSTEM CONSTRUCTION
IT New Installation ❑ Alteration
BU! .DING USAGE TYPE
❑ Repair
Dwelling ❑ Transient Use ElComm./Industrial ❑ Non -Domestic
- _......
._ ----- --._._..------...
❑ Other Describe
' INVOLVED PARTIES
Property Owner:.t-S/}U �2- SA.Mu&i_ Phone. ( 97-0 �36 7 �_i
Mailing Address: IP. G P G'r !,j; G S ) 4 f- CD 16.•� ;
Email Address: (Z5iZ_U z_ c) 0 C6--
Contractor: S A Nt 6 4k c•V C Phone:
Mailing Address:
: Email Address:
Engineen i 6
5 W(I h^Y 5A6 ell e_fa17 y Phone: ( q -0) _
Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION_
Job Address.
Assessor's Parcel Number: Sub.,�V0 7 Lot-__ Block
Building or Service Type:%;, 1) �A LA #Bedrooms: 2 Garbage Disposal(Y/N)- V e__5
Distance to Nearest Community Sewer System- /,% A-
t -
Was an effort made to conne5
1to the Community Sewer System: _/-/A-
Potable Water Source
& Type
Well ❑ Spring ❑ Stream or Creek ❑ Cistern
❑ 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
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.
Property Owner Print and Sign Date
OFFICIALUSE ONLY�(�Z3.°.=
Special Conditions:
Permit Fee:
412:06
Total Fees:
4I-43 9'?
Fees Paid:
412-3.a-
Building Permit
OwTS Permit:
Issue Date:
Balance Due:
BLAE - `gQ 3
se"- ri8g4
Z
Garfield County Public Health Department:
'14
Signed Approval
Date