HomeMy WebLinkAboutApplication1-95 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Health
OWTS PERM IT APPLICATION
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2014 Blake Avenue
Glenwood Springs, CO 8L601
(970194s-66r4
Gaffield Coun$
TYPE OF SYSTEM CONSTRUCTION
E[ ltlew lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGEWPE
K Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
Mailing Address
Email Address:
one:
c-o 7-
7
Property
MairingAddress: ir55 e R z37t S i lt; Co ?t&SL
Email Addres s, j i mloc,,-Ler 3 g OQi\ nicz't / -
Contractor 7a tO
a
JF well tr Spring E Stream or Creek E CisternPotable Water Source
& Type E Community Water System Name
INVOTVED PARTIES
Engi e:
Mailing Address:
Email Address:A/
PROJECT TOCATION AND DESCRIPTION
Job Address:O
Assessor's Parcel Number: Ll 2-72Y ooaT Zlub._lot_Block_
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Building or Service Type:3 Garbage Disposal(Y/N)-
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditio.nal .upo.n such further
niandatory arrd addttibnal tests and rdports as may be rbiulred by tlre local heulth de-partttent to be
made and furnished by the applicant oi by the locdl health department for purpose of the evaluation of
the application; and tlie issuince of the pbrmit is subject to such terms and conditions as deemed
neceis'ary to iniure compliance with rulds and regulaiions 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 be'st of my knowledge and belief and are designed to be relied on by the local
department of health in-evaluatinf the same for purposes of issuing the. permit a.pplie.d for herein. I
fuither 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.
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Property Owner and
Special Conditions:
Total Fees:brn.oo oob@Fees Paid:Permit Fee:oolfr).
Balance Due:tBuildins Permit
BtJYiFQTaQ #fHrqcl lssue Date:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
04/10/2025