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L95 W. 14th Street
Rifle, CO 81650
(e7o) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)94s-6674
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OWTS PERM IT APPLICATION
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Mailing Address:
Email Address:
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EmailAddress:
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Job Address:
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Building or Service
Distance to Nearest Community Sewer System:
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Garfield County Public Health Departrnent - irirorking to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory 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 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 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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Owner Pri Date
Special Conditions:
Total Fees:(o@.oo Fees Paid:
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OWTS Permit:
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lssue Date:Balance Due:A-Building Permit
PraF--$51\
Garfield County Public Health Department:
Signed Approval Date
Garfield County Pubtic Health Depadment * working ta promote health and prevent dioease
3/12/2024