HomeMy WebLinkAboutApplication-PendingGuffield County
Public Heulth
195 w. L4th street
Rifle, CO 81650
(s70) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)94s-661.4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation fl Major Repair E Minor Repair Alteration E Vault and Haul
BUILDING USAGE TYPE
P Dwelling E Transient Use n Comm./lndustrial tl Non-Domestic
E Other Describe
INVOTVED PARTIES
Property own erMis-Phone:
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Mailing
Email Address:ct.na<y'norni s @- qfi*c"-iL. c-a-*
Phone: (
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Mailing AddresS:
Email Address:
Contracto
)Engin ( i'
Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
Distance to Nearest Community Sewer Systemi
Was an effort made to connect to the Community Sewer System
Ga rbage
Assessor's Parcel Number
Job Address:
Building or Service Type
E Cistern
E Community Water System Name
pwelPotable Water Source
& Type
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 department 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
necessary 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 applied for herein. I
further understand that anyfalsification or misrepresentation may result in the denial of the
application or revocation of any permitgranted based upon said application and legalaction 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 kn r rt
Property Owner Print d Sign
Special Conditions:
Permit Fee:@ fees:oo Fees Paid:oo
Building it:lssue Date:Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease