HomeMy WebLinkAboutApplicationRECEIVED
$,lAR 2I 20?2
GARI.IËLD COUNTY
cOrtrUUHtfV DEVELOPMENT
Public Heulth
195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7ol94s-6674
OWTS PERM IT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation n Alteration D[ Repair
BUILDING USAGE TYPE
m Dwelling E Transient Use tl Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Pa 2Property Own
Mailing
Email Address:
Mailing Address:
Email Address:
7
@-CI
E
Mailing Address
EmailAddress:
BuildingorServiceÏype:-*ged¡ooms:3GarbageDisposal(Y
Was an effort made to connect to the Community Sewer System:NTT
ock
Ntr
Assessor's Parcel Nu
Job Address:
Distance to Nearest Community Sewer System:
PROJECT TOCATION DESCRIPTION
tr Spring [] stream orcreek E CisternffwettPotable Water Source
& Type ! Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory 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, 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 anyfalsification 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 Own Sign Date
oFFlclAL UsE ONLY "{. $/$l o o C.c'Òs/zs/zozzàÐ
Special Conditions:
Permit Fee:t?t. "0
Total Fees:
* ?t. no
Fees Paid:l?1. "o
Building Permit
BLMF-?&+o8
OWTS Permit:
.sEPl-?et 09
lssue Date:Balance Due+dÍ
Garfield County Public Health Department:
Signed Approval Date
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