HomeMy WebLinkAboutApplication195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
RECEIVED
.JAN 2 7 2022
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
2014 Blake Avenue
Glenwood Springs, CO 81601
(970l, 94s-66t4
OWTS PERMIT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
& New lnstallation tr Alteration tr Repair
BUITDING USAGE TYPE
N Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
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PROJECT TOCATTON AND DESCRIRTION {,
,oors f. uarbage Disposal(Y/N) Y
Was an effort made to connect to the Community Sewer System:
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Distance to Nearest Community Sewer Systeml
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fBedBuilding or Service Type , ?,es.'o*ì..o I
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Assessor's Parcel Num 2tt1
Job Address:
E Stream or Creek E Cistern{wetl tr SpringPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application isconditional .rpo.n such further
niändatory and addiiional tests and réports as may be required by the local health department to be
made andÎurnished bv the applicant or by the locål healtñ department for purpose of the evaluation of
the application; and tlie issuárice of the permit is su.bject to such terms and conditions as deemed
neceésãry to iniure compliance with rulés and regulations made, information and.reports submitted
herewith'and required tö be submitted by the apþlicant are or will be rep.resented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the,local
department of health in-evaluatinf the same for purposes of issuing the permit applied for herein. I
furiher understand that any falsifiıation or misrepresentation may result in the denial of the
application or revocation of any permit granted b'ased upon said application and legal action for perjury
as provided by law.
CERTIFICATION
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 Print and Sign Date
OFF¡CIAI USE ONLY Pd ,.f ,Zg.oo c.c. otltt/zozzæ
Special Conditions:
Permit Fee:
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Total Fees:
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Fees Paid
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Building Permit
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OWTS Permit:
se?î -1tzo lssue Date:Balance Due: ^r.d
Garfield County Public llealth Department
Signed Approval Date