HomeMy WebLinkAboutApplicationRECEIVED
JUL 1 1 2024
8nT5,iFi3'ff,y'*#
Public Heulth
195 w. 14th street
Rifle, CO 81650
(e70) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-6614
OWTS PERM IT APPLICATION
Garfteld Counp
TYPE OF SYSTEM CONSTRUCTION
New lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
ft Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
tr Other Describe
INVOLVED PARTIEQ ,t-a -\_--,^4
Property (Y*D) 9t K f)k-(T
Mailing 9 22
Email Address:bo*c-o) 1(3 T\
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Mailing Address:
Email Address:
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Mailing Address:
Email Address:
PRoJECTTOCATIONAllDDESCRIPTION _ A
Job Address:
Assessor's Parcel Nu I 3cs2{?
Building or Service Type:?SN
Distance to Nearest Community Sewer System:11
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
{wen tr Spring El Stream or Creek E Cistern
E CommunityWater System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is_conditional upon such furthermandatorv and additional tests and reports as may ul iEiiiir"t uuin;i;;;ih;;ilffi.ilhr"n, ,o u"made and furnished by the applicint ;; bilh" toceit treatifr u"piiin"nt for purpose of the evaruation ofthe application; and ttie issujriie ;iih'; ;tmit ;;;bj'ili;""i.i't'lrr. ,nu conditions as deemednecessary to insure compriance with rures ,"9 19gy]9iigffirai., i1,1;ril;;;;;;';*;,., submittedherewith and required to ue Joriii;; ilih"-rpplicant are or will b.e represented to be true andcorrect to the best of mv knowredge and'Gl[f-;il;;;;;ris;Jio be reried on by the locardepartment of health in'evatuatin;ir'u iri]-" t-o-l. purposes of issuing the. permit applied for herein. Ifurther understand ttt.t any iiiiili;rt;;;;;is.representation may resurt in the deniar of the
:f lil:iLi""t"#evocation
of anv pei'it e'.a"i;J b5;;d ;;liiljil'l[pri;;iil; ;;;l;;j;;iiln ror perjury
I hereby acknowtedge that r have read and understand the Notice and
well as have provided the required information which is correct and a
Certification above as
ccurate to the best ofmy
Property Owner print and Sign Date
L
OFFICIAL USE ONLV
Special Conditions:
Permit Fee:d Fees:co Fees Paid:@
4 lssue Date:Due:
Garfield County public Health Department:
Signed Approval Date
Garfield county Public Health Department - working to promote health and prevent disease
08/07/2024
08/07/2024