HomeMy WebLinkAboutApplicationRECEI\.I;
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195 W. l,4th Street
Rifle, CO 81650
(970\ 62s-s200
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970l'94s-6614
o WTS PERMIT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
Vault and HaulE Minor Repair E AlterationE Major RepairNew lnstallation
ILDING USAGE TYPE tr Non-Domestictr Comm./lndustrialE Transient UseDwelling
Other Describe
INVOTVED PARTIES
Property Own
Mailing T L.T {be-
Email Address:OJL I,
Enginee t
Mailing Address
Email Address
PROJECT LOCAT]ON AND DESCRIPTION
Job Address:3 &Assessor's Parcel
Building or Service L,D.,oo^r, Q- Garbage D
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:'J.J n
Potable Water Source
& Type
frwett tr Spring E Stream or Creek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Aoolicant acknowledges that the completeness of the application is.conditio.nal upon such further
;i"#;il;;;-;il''til;;iteiij ana rdports as may be rbiuired by the local health de-partment to be
ffii;;;1'f;;iti!f,;;'i-11" ii-ittiri oi uv it'e tocit treatttr depart'ment for purpose of the evaluation of
i'f.tl ""oiii"tlon: and tfioisiuiriie of the pbrmit is subject to such terms and conditions as deemed
;;UIr!;i;jiiliili.ii''ii,r6;;&ith-;utiiano regulations made, information and.reports submitted
il;;ifi1iii.1"fi1'ffi;iil15'6; iuumiitea uy the apbticant are or will be rep.resented to be true and
correct to the bebt of my knowledge and bellef and are designed to be relied on by the. local
;;;;-il;;i ot fteilit' in'evaiuatindlhe same for purposes oi issuing the.permit a,pplie.d for herein. I
fuither understand that any falsiflcation or misrepresentation may result ln tne 0enlal oT Tne
;;;iilti,;;;iiJ"*itidn of i"v pCimit granted b'ased upon said aiplication and legal action for perjurv
as provided by law.
CERT!FICATION
I hereby acknowledge that I have read understand the Notice and Certiflcation above as
well as have provided the required ls accurate to the best of
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Property Owner Print and Slgn Date
t+OFFICIAT USE
Speclal Conditions:
oo ooFees Paid:
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Balance Due:lssue DateOWTS Permit:Bull Permlt
Signed Approval
Garfield County Public Health Department:
Date
Gar6eld County Public Health Department - working to promote health and prevent disease
08/02/2024
08/02/2024