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195 w. L4th street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-6614
Gurfield County
OF SYSTEM CONSTRUCNONg New lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUJSDING USAGE TYPE
Ef Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES I
Property cI
Mailing Address:4o bt.s I
Email Address:L
Co Phone:()
Mailing Address
Email Address:
e:)
Mailing Address
Email Address:
Job Address:
Assessor's Parcel Number:Lot Block
Building or Service #Bedrooms:_Garbage Disposal(Y/N )-
Distance to Nearest Community Sewer System:
WasaneffortmadetoconnecttotheCommunitySewerSystem:
Potable Water Source
& Type
!f,wett tr Spring E Stream or Creek fl Cistern
E Community Water System Name
PROJECT LOCATION AND PTION
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditio.nal upon such further
"i,inOrtoiy
ind addiironal tests and rdports as rnay. be required by the local health de-partment to be
rrj" inO furnished bV the applicant or by the locdl health department for purpose of the evaluation of
if.re rpplii"tion; and tlie issuince of the. pbrmit is su.bjectto such terms and conditions as deemed
neceis'ary to insure compliance with rulds and regulaiions made,.information and.reports submitted
f"r"i"*iit1'rnd required t6 be submitted by the applicant are or will be rep.resented to be true and
lorr".t to the beit of my knowledge and belief and are designed to be relied on by the.local
Oepartment of health in'evaluatin[ the same for purposes of issuing the. permit applie.d for herein. I
irrif.rei understand that anyfalsifiiation or misrepresentation may result in the denialof the
appliCation or revocation of any permit granted b-ased upon said application and legal action for perjury
as provided by law.
CERTIFICATION
acknowledge that I have read and understand the Notice and Certification above as
las ded the required information which is correct and accurate to the best of
D?Dq 2+
Date
o usE
special Conditions:
Paid:oc,oo'"'Ulbo,ooPermit Fee:
Q,oo'&
Balance Due:lssue Date:OWTS Permit:Building Permit
Garfield county Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
08/02/2024
08/02/2024