HomeMy WebLinkAboutApplication-PendingGurfteld Coun$
Public Heulth
195 w. l.4th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970\94s-66r4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation E Major Repair E Minor Repair .l[ Alteration E Vault and Haul
BUILDING USAGE TYPE
{ Dwelling I Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner:ett1TOt 4 bL >"lbb
Mailing Address:
Email Address:
2-C K 3
Ctt"l r Vut C l?t c4)
,\Jl.\(J ()
Mailing Address
Email Address:
Enginee r: La.eg 5taal,+-l Phone:
Mailing Address:
Email Address:Z^e.|q A NtctvV@YO, fo/df
PROJECT TOCATION AND DESCRIPTION
Job Address:1(
Assessor's Parcel Number 5u6. G r.arU Lot 3 etoct I
Building or Service fype: lZg 5 *Bedrooms: 3 Garbage Disposal(Y/N I Y
Distance to Nearest Community Sewer System:I rx, l'<,
Was an effort made to connect to the Community Sewer System V *^q
Potable Water Source
& Type
tr Well E Spring E Stream or Creek E Cistern
E CommunityWater System Name
Garfield County Public Health Department -working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is.conditional upon such further
niandatory and additional tests and reports as may be required by the local health derpartment to be
made and furnished by the applicant oi by the local health department for purpose of the evaluation of
the application; and tlie issudnce of the pbrmit is su.bject to such terms and conditions as deemed
neceis'ary to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be represented to be true and
correct to the bebt 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 a.pplie.d for herein. I
furiher understand that anyfalsifiiation or misrepresentation may result in the denialof 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.
5 f .e- u<, S *,v17 9* 5 6ltw iuz
Property Owner Print and Sign Date
Special Conditions:t
oo,Hffi,*Permit Fee:
t.adn.oc)
lssue Date:Balance Due:h-Building Permit OWTS Permit:
Sqpt-8gLtq
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
