HomeMy WebLinkAboutApplicationGørfield County
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195 w, 14th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-661-4
OWTS PERM IT APPLICATION
Alteration trReE New lnstallation
fl Comm./lndustrial tr Non-DomesticDwellingE Transient Use
fl Other Describe
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Property Owner
Mailing
Email Address:
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OLJ LCo
Mailing Address:
Email Address:
Phone:
Engineer
Mailing Address
Email Address:{\l
one:
Was an effort made to connect to the Community Sewer System
#Bedrooms í)
lock
Garbage Disposal(Y/N)
Distance to Nearest Community SewerSystem:
Job Address:
Assessor's Parcel Number
Building or Service Type
! wett E Spring D Stream or Creek E CisternPotable Water Source
& Type D Community Water System Name
Garfield County Public Health Depafiment - working to promote health and prevsnt disease
Applicant acknowledges that the completeness of the application is conditional upon such further
nìandatory and additional tests and reports as may be required by the local health department to be
made and'furnished by the applicant or by the local health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, ìnformation and.reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best 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 f_or herein. I
further understand that any falsification or misrepresentation may result in the denialof the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
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
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Special Conditions:
Total Fees:*?L"o Fees Paid:I 75.,oo
Permit Fee:-f?t.qo
OWTS Perm¡t:
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lssue Date:Balance Due:tr'Building Permit
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Garfield County Public Health Department:
Sígned Approval Date