HomeMy WebLinkAboutApplicationRECEIVËD
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GARFIELD COUNTY
OOMMUNITY DEVELOPMENT
Public HeøIth
195 W. l-4th Street
Rifle, CO 8L650
(e7o) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7o) s45-6614
BUITDING USAGE WPE
Dwelli
OWTS PERM IT APPLICATION
n Transient Use n Comm./lndustrial U Non-Domestic
PROJECT TOCATION AND DESCRIPTION
Gørfield County
New lnstallation
TYPE OF SYSTEM CONSTRUCTION
tr Alteration n Repair
I Other Describe
INVOLVED PARTIES
3lì
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Property Own
\
SqÞo 6ox
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Mailing Address
EmailAddress:
Phone: ( I
Mailing Address
Email Address:
Contractor; t€ f)
Phone:
ts
Enginee
Mailing Address
Email Address:
Bf well n Spring n Stream or Creek n CisternPotable Water Source
& Type I Community Water System Name
Job Addressr rtr -
Assessor's Parcel Number
Building or Service Type 3 Garbase Disposal(Y/N I Y
Distance to Nearest Community SewerSystem:I nt.!t t
Was an effort made to connect to the Community Sewer System:
o
s:
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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 knowl
2z >L
gn Date
Applicant acknowledges that the completeness of the application is conditio.nal upon such further
"iJnAãtoiy
ãn¿ aOOiiional 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.purpo.se of the evaluation ot
tf.¡Ëãpótiðatìon; rÀ¿ the issuánce of the pêrmit is subject to such terms and conditions as deemed
ñe."isàry to iniure compliance with rulés and regu.laiions made, information and.reports submitted
¡,ãiã*iifr'rn¿ iequìred tå be submitted by the apþlicant are or will be rep.resented to be true and
ðòrrect to the beit of my knowledge and belief and are designed to be relied on by the local
ãéó.rtr"nt of health in'evaluatinf the same for purposes of issuing the permit a.pplied for herein' I
fulttrer understand that any falsifiıation or misrepresentation may result.in the denial of the
rppiicrt¡on or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
P
oFFtcrALusEoNLY Þ¡ro + 123.êto cK.{! nq| otlzl- Izczz-fu.
Special Conditions:
Fees Paid:
+ lz3.ooi 123.æ
Total Fees:Permit Fee:
ôò$r
lssue Date:Balance Due:+Building PermÍt
Brr,rF -111S
oWTS Permit
sePT.111 6
Signed Approval
Garfield County Public Health Department:
Date
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:.;:::,:::'¡l ill i iill-rl
10/26/2022