HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 8L650
(970) 62s-s200
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2014 Blake Avenue
Glenwood Springs, CO 81601
(970) s4s-6614
OWTS PERMIT APPLICATION
Guffield County
TYPE OF SYSTEM CONSTRUCflON
New lnstallation D Malor Repair fl Minor Repair E Alteration E Vault and Haul
BUITDING USAGE WPE
fi Dwelling E Transient Use n Comm./lndustrial n Non-Domestic
ElOther Describe
INVOTVED PARNES
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MailingAddress
Email Address:
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Mailing Address:
EmailAddress:
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Engi
Mailing Address:
EmailAddress:
Was an effort made to connect to the Community Sewer System:
PROJECTLOCATION AND
JobAddress: q \ G
Garbage Disposal(Y
AJ-
Assessoy's Parcel Nu
Building or Service Type
Distance to Nearest €ommunity Sewer System:
X weil tr Spring E Stream or Crcek E CistemPotable Water Source
& Type E Community Water 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
mandatory 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 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 td 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 apRlied 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
my knowledge.
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Property Owner Print and Sign Date
Special Conditions:
Total Fees:@ldn ooFees Pald:(o@Permit Fee:ookn
lssue Date:Balance Due:HBuildlne PermitgixE-q\rc OWTS Permit:
eFPr.q\31
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
03/21/2025