HomeMy WebLinkAboutApplicationREGEIVED
JAN 20 ?t2?
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i-95 w. 14th street
Rifle, CO 81-650
(e70) 625-s200
Public Health
OWTS PERMIT APPLICATION
Ü Alteration tr Repair
lD Comm./lndustrial ltr Non-Domestic
201-4 Blake Avenue
Glenwood Springs, CO 81.601
(970) e4s-6614
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Gøffield County
¡NVOLVED PARTIES
I Property Owner:t+þMailing
Email Address:
Engineer:
MailingAddress:
Mailing Address:
Email Address:
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DESCRIPT¡ON
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BuildingorServicefype: N¿lør€ *Bedrooms: I GarbageDisposal{Y/N't yq
Distance to Nearest Community SewerSystem:
Was an effort made to connect to the Community Sewer System:
Assessoy's Parcel Number:Lr7-13L7o
i Potable Water Source
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Well E Spring E Stream or Creek E Cistern
ì E CommunityWaterSystemName
Garfield CountV Public Health Department - working to promote health ancl prevent disease
CERTIFICATION
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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.
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Property Owner Pri Date
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Special Conditions:
&*Fees Paid:* r¿goê
Total Fees:Perm¡t Fee:f le3.oo
Due:Balance
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lssue Date:OWTS Permit:
SEPT'-13T 3Building Permit
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Garfield County Public Health Department:
Signed Approval Date