HomeMy WebLinkAboutApplicationGurrteW County
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
Mailing Address:
Email Address:
Public Heølth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7ole4s-6614
Phone
LO
C.o
PROJECT I.OCATION
WPE OF SYSTEM CONSTRUCTION
Repairtr Alteration
BUITDING USAGE TYPE
New lnstallation
tr Comm./lndustrial Non-DomesticE/Dwelling I Transient Use
E Other Describe
INVOTVED PARTIES
Co
Property
Mailing Address:
Email Address:
Email Address:
Contractor:
Mailing Address:o, Co 8t bY'?lD 3or q qq New
Was an effort made to connect to the Community Sewer System:
Garbage Disposal(Y
NO
6 /N) \
Distance to Nearest Community SewerSystem
+Building or Service Type
Assessor's Parcel Number
Job Address:
' ? ,nìtps
! Stream or Creek fl CisternWellE SpringPotable Water Source
& Type fl Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
'l
Applicant acknowledges that the completeness of the application is.conditional upon such further
nìandatory and additlonal tests and reports as may.be required by the local health department to be
made andÎurnished bv the applicant or by the local health department for purpose of the evaluation of
the application; and tlie issuárice of the pèrmit is subject to such terms and conditions as deemed
neceisary to iniure compliance with rules and regulations made,.informatíon and.reports submítted
herewith'and required tó be submitted by the apþlicant are or will be rep.resented to be true and
correct to the beit 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
fuither understand that any falsifiıation or misrepresentation may result in the denia.l of the
aþplication or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
ON
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.
/2-8- Zozt
Pri Sign Date
oFFrcrAL usE oNLY P¡. $ l¿3.ô c Cñ* /,321 tz/tt/r'asr é1)
Special Conditions:
Permit Fee:
Sf ag. n*Total Fees:
"f , a,g. o*Fees Paid:
.$ d ?.9. â"
Building Permit
ßun€ "?a?*#
OWTS Permit:
sãrp* ?e ? ff'
lssue Dater Balance Due:,td
Garfield County Public Health Department:
Sígned Approval Date
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