HomeMy WebLinkAboutApplicationGørfield County
195 w. 14th street
Rifle, CO 81650
(e70) 62s-s200
Public HeøIth
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation H Alkeration
Dwelling E Transient Use Ð Comm./lndustrlal
E Other Describe
INVOI-VÊD PARTIES
Property Owner
Mailing Add ok 1¿/o V 6 5^2
EmailAddress:-1o ø4
Mailing Address:
Email Address:
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2014 Blake Avenue
Glenwood Springs, CO 81.601
(970) s4s-6674
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ark
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BU¡LDING USAGE TYPE
fl Non-Domestic
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Mailing Address: 2 5^/ é
Potable Water Source
& Type
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PROJECT LOCATION AND DESCRIPTION
Job Address:VL Yf\¿vY\¡^¡V
¡Assessor's Parcel Numbe ,' J /&/- ,CS-&-¡l
Building or Service
Distance to Nearest Community SewerSystenu 3*, /c<
Was an effort made to connect to the CommunitySewer System:'ll I
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3 carbage Disposallvtnl I
Well il splrg El Stream or Creek fl cistern
WaÞrsfffmName (I r'l
Garfield County Public Health Departtnnent - working to promote health and prevent disease
Applica.nt acknowledgesütlatthe completeness of the application is conditional upon such furthçr
mandatory-and additionrdl@ts.and reports as may be required by the local health department tb be
made and furnished byülneapplicant or by the locãl health depart'ment for purpose oi the evaluátion ofthe application; and the iim¡¡ance of the permit is subject to such terms and'cond¡tions as deemed
necess.ary to jnsure cornp$iance with rules and regulations made, information and reports submittedherewith and require-d to be submitted by the apþlicant are or will be represented tó be true and
correct to the best of rny lknrcnwledge.and belief and are designed to be rólied on by the local
department of hea.lth in evdluating the same for purposes ol issuing the permit applied for herein. Ifurther understand thata{nyfalsification or misreþresentation mav-resuli ¡n the d'en¡alof the
application,or revocatiornof any perm¡t granted based upon said application and legal action for per;ury
as provided by law.
G
I hereby acknowledge drd ll have read and understand the Not¡ce and Certification above as
well as have provided tlrcrquired information which is correct and accurate to the best of
my knowledge.
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Property Owner Print sEn Dete
Spec¡â¡ conditions:
ccParmit Fee:* tzt Total Fees:I lzt. oo Fees Paid:* lzg. o.
Building Permit
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ñrlll5Pcfmlt:sePr.1c6z lssue Date:Balance Due:id
Garfield County Public Healdr DqF.trrent:
Signed Approval Date
I'lr:,i i rr1 J
! I'rlrl(tl l)r.-.llll ¡
07/21/2022