HomeMy WebLinkAboutApplication - ORIGINALGarfteld County
195 W. 14th street
Rifle, CO 81650
(970) 62s-s200
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OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(e70l.e45-66L4
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flOther Describe
OF SYSTEM CONSTRUCTION
New lnstallation l n_ Maprnepgil | _n- Min-ofnepail J - Atleration _l n_v9_u!{altgy!
TDING USAGE WPEBUIdDwelliE Transient Use tr Comm./lndustrial n Non-Domestic
PropertyOwner: GUY MIDDLETQN Phone:e7qeE52e0o
Mailing 1912 COUNTY ROAD 311 NEW CASTLE CO 81647
Email Address; gmpumper@icloud.com
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Mailing Address
EmailAddress:
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Mailing Address
EmailAddress:
PROJECT LOCATION AND DESCRIPnON
Job Address:
Assesso/s Parcel
Building or Service Manufactured Home 3 Garbage Disposal(Y/Nl--Nl
-Distance to Nearest Community Sewer System:N/A
was an effort made to connect to the community sewer system:
E Stream or Creek
! Community Water System Name
Potable WaterSource
&Type
Garfield Cr:unty Public Healtt-r Department *- working to pronrr:tr: healtir errrd prevent disease
] CERTIFICATION
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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Propefi Owner Print and Sign
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Date
OFFICIAL USE ONLY *f[cy. S-lro.X{
Special Conditions:
Permit Fee:
I ^rxz @ Total Fees:ca(&),Fees Paid:
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Building Permit
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OWTS Permit:
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lssue Date:Balance Due:-e-
Garfield County Public Health Department:
Signed Approval Date
05/30/2024