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RECËIVEÞ
ûtT i t 7021
-i¡¡RFIELD COUNTY
. NùtMIINITY DEVELOPMENT
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-6614
10l2ol21,6:50 AM
Publíc Health
195 w. 14th Street
Rifle, CO 81650
(97Or62s-52æ
OWTS PERM IT APPLICATION
Garfield County Public Health Department - working to promote health and prevent disease
Gørfield County
WPE OF SYSTEM CONSTRUCTION
if- Ñew lnstallation E Alteration E Repair
BUITDING USAGEWPE
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I il-Dwellíng Û Transient Use tr Comm./lndustrial Non-Domestic
E other Desgibe
INVOLVED PARNES
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P'ROJECT TOCANON¡ A¡¡D DESCRIPTION
D¡stance to Nearest Commun¡ty Sewer System:
Was an effort made to connect to the Community Sewer System:
-
Assesso/s Percel Number:
tÐ lta Garbage Disposal(Y/N)-
Lc7. 2a?
Job Address:
Building or Service
E Stream or Creek E Cisterntr Well tr Spring
E Community Water System Name
Potable Water Source
& Type
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(6 unread) - sunny6398@yahoo.com - Yahoo Mail
Back 0lilT$-Applieat¡on-Complete-pãeket-Dec'-2019-Bdf Pag*'1 oi-
I herebyacknowledge that I have ¡ead and understand thê Notice ¡nd Certlficatlon abve as
w6ll as have provided the required infomatlon which ls correct and to the best of
myknowledge.
'lol2Ùl21,6:50 AM
EJ
ProprtyOwner Print and Sign Date
Aoplícant acknowledges that the completeness of the application is conditional upon such further.'r,iñà;ì;;t¿|¿
åddi-i"ional tests and réports as may be requíred by the local health department to be
mã¿ã àna trrnished bV the applícant or by the local_h,ealth department for.purpo.se of the evaluation of
the application; and the issuance of the permit is su.bject to such terms and cond¡tlons as deemeo
ñài,"Jsãrv täì"iure compliánce with rulËs and regulalions made, information and.reports submitted
i.iãiewiitr'an¿ iéquired tð be submítted by the apÞlicant are or will be rep.resented to be true and
.ıii"àüoìttã u"h oi my knowledge and belief àñd are designed to be relied on by the.local
ããoart.ãnt of health in'evaluatinãthe same for purposes of issuÍng the. permit a.pplie.d lqr herein- I
further understand that anV falsification or misrepresentation may result ¡n the denlal ol tne
ıpii*t'd"iiãvocation of any permit granted based upon said application and legal action for periury
as provided by law.
Special Corditlons:
Fees Þald:* lzz.aTotal FeeslÌ125. *oPemitFee:* tu3,.aa
Balance Duer,rølssue DaÞ:OWTSPêrmit:
Seer -1zoT
Bu¡ldlng Pêrm¡t
gves¡. 1 l1R
Garflcld County Public Healfü Department
DrbsignedAppþml
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