HomeMy WebLinkAboutApplicationRECEIVED
GARFIELD COUN
COIÌllYlUNlTY DFVE t OPM
195 W. 14th street
Rifle, CO 81650
(970) 62s-s200
Public Health
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(e7o) e4s-6614
Gørfield County
TYPE OF SYSTEM CONSTRUCTION
n New lnstallation
BUITDING USAGE WPE
a ow"lliie- ---i n iråns¡ãnfÚ!"
trRe
m./lndustrial I n ruon-oomesiii
E! Alteration
fl other Describe
I
Mailing Addressi
INVOTVED PARTIÉS
Property
Malling
Email Address:l,t)Dy u n r---l 6),/.¿'o:lë7
Emall Addressr
PRO'ECT TOCATION AND DESCRIPÏION
Job Address:/'7âf'l1_
Assessor's Parcel
Distance to Neârest Community SewerSystem:
Was an effort made to connect to the Communlty Sewer Systeml
Potable Water Source E Well Spring E Strean or Creek fl Clstern
& Type E Communlty Wat€r System Name
(l
MailingAddressi
-
Email Address:
Bullding or Ser uicetype, Roor|/no /r'o/ /Joo-il'n{Aoedrooms:--/
-Garbage
Disposal(V/rrr) f/
Garfreld Cor-rnty Public Health Department -. working to promote heallh ancl prevenl disease
åtf;iT,î".i'"1trîJåis,öig,î!ffiËdîTriå!'diy'þ:rual]*i"i;'fii#ifiå[i.,iis:xiiil*",
ffiX'r'rlfllfåf','!;l I'flli,fffJfi?ifr{3li¡i1",;¿ial;,;¡ i"rms ana'*Åd¡t¡ons as deemed
necessarv ro insure .on.,åi"r*iä*¡t'rt'ilr.ärno r"i,ìlãtiJñiin-r¿å, information and reports submitted
herewith'and required t$'i,i tïUäiiiåäËiiüã "p"piäì;;; "¡úillbã
rept"sented td be true and
correct ro the best or ry"t"Joi,itäU;;;;ð'båli;fäñd ãre Jesigned to be rélied on bv the local
deoartment of health in evaluating the same tor pürposãs oi issuing the permit applie.d for herein' I
i;.iil'ñå;itäiäï¡,åi Jñi irjili¡Ëition or misreþieientation maylesult in the denial of the
aoorication or revocat¡ono;r;il'ffiií,:ilå;tc,,î bãlËd uþon said apprication and regar action for perjury
ai þrovided by law'
CEBTIFICATION
I hereby acknowledge that I have read and understand the Not¡ce and certification above as
well as have provided the requlred lnformation whlch is correct and accurate to the best of
my knowledge.
I - Arr-Al
Property Owner Prlnt a nd Date
60oFFrclAtû
Special Conditions:
oôFees Pald:gFees¡Òô
oolssue Dâte:
CI
oWTS Permit:Perm¡t
Sl¡ned APProval
Garfleld County Publlc Health Department:n C¡érlzlri¿zr
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