HomeMy WebLinkAboutApplicationGarftcld CountY
Public Health
195 W. 14fr street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81501
(e70) 94s-6514
OWTS PERMITAP P LICAT roN
El Vault and HaulE AlterationEl Minor rrn New lnstallation
E Non-DomesticnE Transient Use
Other Describe
/60/Property
Malling
Cmail Address:
MailingAddress:
Email Address:
Was an effort made to connect to ttre Community Sewer System: h$
Job Address:CU
Disposal{Y/Nl 7
Assesso/s Parcel 7l
Building or Service
Distance to Nearest Community Sewer System:
D Stream or CruekE Sprlng fl Chrerntr Well
@nrunltywat€rsptemName
Potable Water Source
&Type
Garlield County Public Heallh Department-working to promote health and prevent disease
(i :l ir ;: I t 1il,,.\r ll {r I rl
Appltcant acknowledges that the completeness of the applicatlon isconditional upon such further
rdfii;i;-il;iiO JOUitTonai teltC inO rriports is may be rbbuired by the local health de_partment to be
"iil-g;i'fuinlstria Uv tttJap-pttiant o? bv ttre tocit trealtli departhent for purpose of the evaluation of
ttiiipptiiatioru Jnd tlie lssuirice of the pbrmlt is subject to such terms and condltlons as deemedil;j$w t;lniure comptianie wlth ruldsand regulaiions rnade, lnformation and reports submltted
iieiJwiiir'airo [ouiria 16 be Juumittea by the ap-pltcant are or uilll be represented to be true and
iorria io itrl bl-st oi mv knowledee and belief ind are designed to be rilied on by the.local
OlpJrtmtnt'oftriatitr in'eviluatin[ the same for purposes oT issuing the. permit appf e.d for hereln. I
turitrli unUeistina itrai anv falsifiEation or misre'pre'sentatlon may result ln the d'enlal of the
;ppiffifion oirevocitton of any permit granted bbsed upon said ahplication and legal action for perjury
as provlded by law.
I hereby acknowtedge that I have read and understand the Notice and Certification above as
wett as have provided the required information whlch is correct and accurate to the best of
my knowledge.
Propefi Print Sign Date
Special Conditions:
Fees Paid:oo(od),Crc)
Total Fees:Permit Fee:(;rmr @
Balence Due:bffif*q6a1Q lssue Date:BuililingPermit
Garfteld County Public Health Departmenti
Signed Approval Date
Garfielcl Countv Public Health Deoartment - workino to nromote health and orevent disease
05/21/2024