HomeMy WebLinkAboutApplicationGaffield County
1-95 W. 14th Street
Rifle, CO 8L650
(970) 62s-s200
PublÍc Heølth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970l.94s-6614
WPE OF SYSTEM CONSTRUCTION
tr AlterationNew lnstallation tl Re tr
tr Dwell tr Comm./lndustrial
BUILD¡NG USAGE TYPE
! Transient Use Non-Domesticn
Other Describe
INVOTVED PARTIES
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i
Property
Mailing Address
Email Address:
neCont
Mailing Address:
EmailAddress:
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Mailing Address:
EmailAddress:
PROJECT LOCATION AND DESCR¡PTION
Was an effort made to connect to the Community Sewer System:
Assessor's Parcel N
Distance to Nearest Community SewerSystem:N/,r
Nlr
Job Address:
Building or Service Type Garbage Disposal(Y/N)_
b.-[ot-Block
-
tr Well ! Spring ! Stream or Creek n CisternPotable Water Source
& Type ( Community Water System Name
Garfield County Public Heallh 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.
r¡J
Property Owner Print and Sign Date
Applicant acknowledges that the completeness of the application is.conditíonalupon such further
nìandatory and additionaltests and reportsas 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 tlie issuance of the permit is subject to such terms and conditions as deemed
neceésãry to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tò be submitted by the applicant 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 evaluatinf the same for purposes of issuing the. permit a.pplied for herein. I
fuither 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.
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Special Cond¡t¡ons:
Permit Fee:
t5a- OO
Total Fees:oo\ â3.
Fees Paid:oo'\A3 t
Buildine Permit
Bu(E-ßort
OWTS Permit:
5¿e+-*ots
lssue Date Balance Due:
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Garfield County Public Health Department:
Signed Approval Date
04/13/2023