HomeMy WebLinkAboutApplicationGørfield County
Publíc Healtlt
195 W. L4th street
Rifle, CO 81650
(970)62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
O\,\TTS PERM IT APPLICATION
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TYPE OF SYSTEM CONSTRUSflOII
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Elother Describe
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PROJECÎ LOCATION AND DESCRIPTION ¿, ?l -^ -
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sanrer System:ño
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Assessol's Parcel
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Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATTOTll
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additionaltests 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 permít is subject to such terms and conditions as deemed
necessary to insure complíance 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 falsificatÍon 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.
I hereby acknowledge that I have read and understand the Not¡ce and Certif¡cat¡on 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 and Sign Date
dJi'<L-*\OFFICIAL USE
Special Condftions:
Permit Fee:C,O(o Tot¡l Fees:c/o cvc(oOOFees hid:
Building hrmit OWTS Permit:
SF,çf- K4.2s
lssue Date:
Garfield C.ounty Public Health lÞpartmênt:
SlgnedApproval Date
8/14/2023