HomeMy WebLinkAboutApplicationGaffield County
195 w. 14th street
Rifle, CO 81650
(e70) 62s-s200
Public Health
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L601
(e70) 94s-6614
OF SYSTEM CONSTRUCTION
n Alteration n Repair
n Comm./lndustrial Non-Domestic
BU
New lnstallation
NG USAGE TYPE
! Transient UseDwelling
E other Describe
INVOTVED PARTIES
Property
Mailing
Email Address:
(
MailingAddress
Email Address:
( 7Vo | flY -et'ã<lEngi
Mailing Address:
Email Address:
Was an effort made to connect to the Community Sewer System: [l&
,oornr .L Garbage Disposal{Y/Nl h/
ock
NA
PROJECT LOCAT¡ON AND DESCRIPTION
Job Address:
Assessol's Parcel Number
Distance to Nearest Community SewerSystem:
Building or Service
E Stream or Creek E c¡sternn Well E SpringPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
I
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I
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mándatory 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 wíth rules and regulations made, information 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 for herein. I
further understand that any falsification or misrepresentation may result in the denial of 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.
DateProperty Owner Print and Sign
oFFlCfAt USE oNLY ?ArD $tZ3.o" c. c. oz/r.Olzszr;St>
Special Conditions:
Permit Fee:
# 127'ð
Total Fees:4 tz3.@
Fees Paid:
4 lz_3.a
Building Permit
gvz-e-1?çt
OWTS Permit:
sePT -134 6
lssue Date Balance Due:þ6
Garfield County Public Health Department:
Signed Approval Date
02/22/2022