HomeMy WebLinkAboutApplicationGarfteld County
Public Heulth
L95 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-66t4
OWTS PERM IT APPLICATION
TYBE OF SYSTEM CONSTRUCTTON
Ef New lnstallation tr Alteration tr Repair
BUIJÐING USAGE TYPE
Ef Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
EIOther Describe
INVOTVED PARTIES
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Property
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PROJECT TOCATION AND DESCRIPTION
Was an effort made to connect to the Community Sewer System:
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rbage Disposal(Y/N)-f-
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Distance to Nearest Community Sewer System:
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Building or Service
tr Spring El Stream or Creek E CisternTå'we|.Potable Water Source
& Type E Communlty 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 Not¡ce 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 Owner Print and Sign Date
Applicant acknowledges that the completeness of the application is conditional .uPo.n such further
niandatory and additionaltests and réports as may be required by the local health department to be
made and'furnished by the applicant or by the locál health department for purpose of the evaluation of
the application; and the issuance of the pèrmit is subject to such terms and conditions as deemed
neceisäry to insure compliance with rulés and regulaiions made, information and reports submitted
herewith-and required tó be submitted by the apþlicant are or will be represented to be true and
correct to the belt 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 f-or herein. I
further understand that any falsification or misrepresentat¡on 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.
OFFIC¡AL USE "%ìd Cçfroas { \a},oo
Special Conditions:
Perm¡t Fee:\^b:o 'iä"ä'.""Fees Paid
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Building Permit
ßt¿E -1åb3 OWTS Permit:
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lssue Dete:Balance Due:+r
Garfield County Public Health Department:
Signed Approval Date
2/2/2023
02/02/2023