HomeMy WebLinkAboutApplication-PendingGar ld County
195 w, 14th Street
Rifle, CO 81650
(e70) 52s-s200
Fr*d*dsr: #Eswttfz
OWTS PERMIT APPLICATION
2O14 Blake Avenue
Glenwood Springs, CO 81601
(e70) 94s-6614
TYPE OF SYSTEM CONSTRUCflON
tr New lnstallation E Vtajor Repair
BUII.DING USAGE TYPE
Vtr
Dwelling
Other Describe
, dvinor Repair E Aheration fl Vault and Haul,
fl Transient Use --tr cittil.l]nOurtiif -- - n Non-domestic
Mailing Address: _
Email Address:
INVOLVED PARTIES
Property Owner:tQzot 2t ULIT
Mailing {-?lt{a
Email Address:
rclT | 6tr'A?Ei,f,
MailingAddress, /fu( Ce, n 5n
Email Address:
Engineer:_--
PROJ ECT IOCATION AND DESCRIPTION
Job Address:5?-
Assessor's Parcel N
Buildlng or Service Disposal(Y/Nl
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source fr wen il spring E Stream or Creek fl cistem
E Conrmunity Wator gystcrn Narrre& TVpe
Glti'fteld C*utlly llLtf:tir; ilcaitii i-)tt1.;r,irttnl-tr1 -'. ir'{,iili.ijri!; li; ;;ron.ri'rlc heaiih irrrcJ ;:r{iyeirt diss:a*r,;
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 department to be
made and furnished by the applicant or by the locdl health depart-ment for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and coirditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or uiill be represented td be true and
correct to the best of my knowledge and belief and are designed to be r6lied on by the local
department of health in evaluating the same for purposes oT issuing the permit appliea for herein. I
further undcrstand that any falsification or misrepreientation may resuli in the d'ehial of the
application-or revocation of any permit granted based upon said airplication and legal action for perjury
as provided by law.
CERTIFICATION
I hereby achnowledge 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.
Property Print and Sign Date
OFFICIAL USE ONLY I
Special Conditions:
ooPermit Fee:Rm Total Fees:&oo .oo Fees Paid:
-*
Building Permit OWISPermit:S#t-q\\5 lssue Date:Balance Due:
Garfield County Public Health flepartment:
Signed Approval Date