HomeMy WebLinkAboutApplication-PendingGurfield County
Public Heulth
195 w. 14th street
Rifle, CO 81650
(s7ol62s-s2o0
2014 Blake Avenue
Glenwood Springs, CO 81501
(970l-945-66L4
OWTS PER IT APPLICATION
Mailing Address:
Email Address:
Engineer:.Sctpe, t A'2 / O;.a1-t7.'e+ro*tnone: Q/o 1oV O7t (
Mailing Address:
Email Address:
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation E Major Repair E Minpr Repair Ef Aheration El Vault and Haul
BUITDING USAGE WPE
E/ Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic'
E Other Describe
INVOTVED PARTIES
%1b.6\
e:
&1
L
4 { v&e
Property
Email Address:
Mailing
PROJECT TOCATION AND DESCRIPTION a'l/1 /
Buitding or Service Tvpe, lL 64/ obpf/* #Bedrooms: 3 Garbage Disposal(Y/N#-
Was an effort made to connect to the Community Sewer System:
sub.-tot-Block
-*(N
Assessor's Parcel Number
Job Address:
Distance to Nearest Community Sewer System:
E Cisterntr Well tr Spring E Stream or Creek
Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional _upo.n such further
niandatory and additional tests and reports as may be required by the local health de-partment 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
neceisary 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 applie.d 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
Print and Sign Date
OFFICIAL USE
Special Conditions:
fr\L,*Total Fees:ooKDPermit Fee:
,Qcn'oo
OWTS Permit:3r-wqr3q lssue Date:Balance Due:
t33
Buildine Permit
?-t-08-q
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease