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L95 W. 14th Street
Rifle, CO 81650
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Public Heølth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L601
(s7o)e4s-66r4
Gørfiehd County
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EmailAddress:
MailingAddress:
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PROJECT TOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel Number:
Building or Service Type Garbage oisposa@ru¡ I
Distance to Nearest Community SewerSystem
Was an effort made to connect to the Community Sewer System:ii\ /\
Potable Water Source Çl Well ! Spring t Stream or Creek fl cistern
E Communlty Water System Name& Type
Garfield County Public Health Department - working to promote health and prevent disease
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CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
niandatory 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
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 deníal of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provlded 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 Owner Print and Sign Date
OFFICIAT USE c)o
Special Conditions:
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ØFees Paid:
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Permit Fee:I Ao OO
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lssue Date:Balance Due:
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Building Permit
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OWTS Permit:
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Garfield County Public Health Department:
Signed Approval Date
03/09/2023
03/09/2023