HomeMy WebLinkAboutApplicationGurJield County
Publíc Health
195 w. 14th street
Rifle, CO 81550
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s_6614
OWTS PERMIT APPIICATI ON
Garfield County Public Health Department - working to promote health and prevent disease
TYPE OF SYSTEM CONSTRUCTION
Ef ruew lnstãllat¡on E Major Repair EI Minor Repair E Afteration E Vault and Haul
BU¡ID¡NG USAGEWPE
EI- Dwelline E Transient Use tr Comm,/lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
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Property
Mailing
Emall Address:a
MalllngAddress:
-1
Emall Address:
MalllngAddress:I s tr
Email Address:-l[^¿
Job Address:
Assesso/s Parcel 7:t
Bullding or Servlce Disposal(v/rrrl Y
Dlstance to Nearest Communlty Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
t Well tr Sprlng E Stream oroeek... |
^
tr C¡stem
L I l.:r . .+
Conrmunlty lâratêr Syslem Name
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Applicant acknowledges that the completeness of the application is csnditlonal upon such further
mandatory-and additionaltests and reports as may be rbluired by the local health department to be
made and furnished by the applicantoi by the locdl health depatt'ment for purpose of the evaluatton of
the appllcation; and the issuance of the permit is subject to súch terms and coñdit¡ons as deemed
necessary toinsure compliance with rules and regulations made, lnformation and reports submitted
herewith-and require-d tó be submitted by the apþlicant are or will be represented tó be true and
correct to the best of my knowledse and belief and are deslened to be rél¡ed on bv the local
department of health ln'evaluatin[the same for purposes oT issuing the permit applied for herein. I
further understand that any falsifiıatlon or misrebreientat¡on may-resuil ¡n the d'eh¡al of the
application.or rgvocation of any permit granted bäsed upon said aþplication and legalaction for perJury
as provided by law.
I hereby acknowledgc that I have read and understand the Not¡ce and Certlflcation aboye as
well as have provlded the requlred inûormatlon which i¡ correct and accuratc to the best of
my knowlcdge.
rb.fl23
Property Owner and Dâte
Speclal Condldons:
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Bulldiñi Permlt
RL0Ë-e4ßK
OWÍS Permhl l33ue Dåta:
Garûeld County Publlc llealth DeprÉment:
DateSlgnedAppronl
Garfield County Public Health Department - working to promote health and prevent d¡sease
10/04/2023