HomeMy WebLinkAboutApplicationGAR,FIELD COI.¡N.ü T
eîruruururrY DEVELoPMEN.T
RECËIVED
195 w. 14th street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New lnstallation El Alteration tr Repair
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-661,4
Gaffield Coun$
BU¡LDING USAGE TYPE
$ Dwelling
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E Transient Use n Comm./lndustrial tr Non-Domestic
INVOTVED PARTIES
Property Owne
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PROJECT TOCATION AND D
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,oo r, 3 Garbage Disposal(Y/N) A)
D¡stance to Nearest Commun¡ty SewerSystem
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, Was an effort made to connect to the Community Sewer System://A
potable Water Source tr well E Spring I E Stream or Creek E Cistern
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Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional "upo.n such further
niandatory and additionaltests and reports as may be required by the local health department to be
made andÎurnished 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
neceis-ary to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tò be submitted by the applicant are or will be represented to be true and
correct to the be3t 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 applie.d 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 Print and Sign Date
Special Conditions:
Total Fees:Fees Paid:
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Perm¡t Fee:
{?s. oo
lssue Date:Balance DueBuild¡ng Perm¡t
x/¡
OWTS Permit:s¡er.-11Sf
Garfield County Public Health Department:
Signed Approval Date
10/24/2022
$75.00
$0.0010/25/2022