HomeMy WebLinkAboutApplicationGarrteW County
Public Heulth
195 w. 14th street
Rifle, CO 81650
(970) 62s-s2oo
2014 Blake Avenue
Glenwood Springs, CO 8160L
(970) 94s-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr Alteration RepairL New lnstallation
tr Comm./lndustrial tr Non-DomesticE Dwelling
BUITDING USAGE TYPE
E Transient Use
E Other Describe
INVOLVED PART¡ES
Property L
MailingAdd 4 s SZ
o,êaEmailAddress:
Contra
Mailing Address:L ./¿"¡Co¿¿a é v l4oo J .zZ¡9 /¿ (c e/69->
aEmailAddress:
Enginee ¿hone:
Mailing Address: C)tt Õ Z{s R,cí)
EmailAddress:
PROJECT LOCATION AND DESCR]PTION
Job Address:87( ru. l^s¿ç C¡ ft CÐ 9t6sz
Assessor's Parcel Number: s uø.ùl 4sc/on /V|ft or tot-=¿-Block
-Building or Service Type:]ZGa rbage Disposal(YlNl lV
Distance to Nearest Community Sewer System 2l t'
Was an effort made to connect to the Community Sewer System
Potable Water Source
& Type
F Well tr Spring E Stream or Creek E C¡stern
E Community Water System Name
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 knowledge.
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Propertypwnéi Pr¡nt and Sign Date
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
necessaryto 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.
IOFFICIAL USE ONtY oô
Special Conditions:,t
Permit Fee4t{3,Ø "'4',i)2.*'""ï'lÞ2.oo
Balance Due:
í d\."o
Building Permit OWTS Permit:lssue Datel
Garfield County Public Health Department
Signed Approval
aq3i¿?9
Date
1/13/2023
01/18/2023