HomeMy WebLinkAboutApplicationGurfield County
Public Health
195 w. 14th street
Rifle, CO 81650
(s7ol62s-s2oo
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation fl lvta¡or Repair E Minor Repair E Alteration EI Vault and Haul
BUILDING USAGE TYPE
F Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
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Property
Email Address:
Mailing
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Mailing Address;
Email Address:
Cal lcv &*Þen CÞU r:JåJ)-Phone:
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Engi tllet Ðc}1 .Clô1neer:
Mailing Address:
Email Address:
PROJECT TOCATION AND DESCRIPTION
D¡stance to Nearest Community Sewer SystemI
Was an effort made to connect to the Community Sewer System:
Assesso/s Parcel
Co. ólbez lJob Address:
Building or Service rbage Disposal(Y/N)-y--
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E Stream or Creek E Cistern
I
tr Well tr Spring
I Gommunitywatersystem nane Cq'tlle- C(eJeE W qþ( ÍIsw,chtiøa
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is.conditio.nal.rPo.n such further
niandatory and addit'lonaltests and reports as may be required by the local health de-partment to be
made andÎurnished by the applicant or by the local health department for purpose of the evaluation of
the application; and tlie issuánce of the permit is subject to such terms and conditions as deemed
neceisary to iniure compliance with rulés and regulations made, information and.reports submitted
herewith and required tò be submitted by the applìcant are or will be represented to be true and
correct to the be¡t 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 anyfalsifiðation or misrepresentation may result in the denialof 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 Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
Llo T*krr 23
Property Owner Print and Sign Date
OFFICIAL USE ONLY \læ
Special Conditions:
*'?äß.oO Fees:,oo Fees Paid crob@
Building Permit #di:+ffi lssue Date:Balance Due
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
07/31/2023
07/31/2023