HomeMy WebLinkAboutApplicationGsrfield County
Public Health
L95 w. 14th street
Rifle, CO 81650
(970) 62s-s2oo
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERM IT APPLICATION
Alteration trRe trNew lnstallation
E Transient Use Comm./lndustrial tr Non-Domestictr Dwell
Elother Describe
one:Property Owne
Email
Mailing Add
()
Mailing Address:
EmailAddress:
Building or Service type: Cs¡^t^ nBedrooms: Garbage Disposal(Y/N)-
Was an effort made to connect to the Community Sewer System:
Job Address:
PaAssessor's rcel
En
Distance to Nearest Community Sewer System:
Lot Block
Mailing Address:
Email Address:
E Spring E Stream or Creek E Cisternrtr wellPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additionaltests and reports as may be required by the local health department to be
màde 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 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 Certificat¡on 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 Owner Print and Sign
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Special Conditions:I
Perm¡t Feei Total Fees:.ûtç2.6 *ffiq.-
OWTS Permit:Sffi:!qsq lssue Date:Balance Due:66.*Building Permit
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Garfield County Public Health Department:
Signed Approval
f
Date
12/29/2022
12/30/2022