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195 W. 14th Street
Rifle, CO 81650
(s70) 52s-s200
544 S<fut +o 1ereaq*
Public Heulth
OWTS PERM IT APPLICATION
TYPE OF SVSTEM CONSTRUCTION
Repair E Minor E Alteration E Vault and Haul
BUITDING USAGE TYPE
E Transient Use tr Non-Domestic
2014 Blake Avenue
Glenwood Springs, CO 81601
(970l.94s-66L4
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Garfwld County
New lnstallation
tr Comm./lndustrialtr Dwelling
E Other Describe
INVOTVED PARTIES
Property
Mailing Address
Email Address:
Phone
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Mailing Address
Email Address:
Contractor:
PROJECT TOCATION AND
Mailing Address
Email Address:
Was an effort made to connect to the Community Sewer System:
G arbage Disposal(YBuilding or Service
Distance to Nearest Community Sewer System:
Job Address:
Assessor's Parcel Number Lot Block
CisternWelltr Spring E Stream or Creek
E Commgnity Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
I hereby acknowtedge 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.hrti
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@Printandsign \")-t
Applicant acknowledges that the completeness of the application is.conditio.nal.rPo.n such further
mandatory and addit-ionaltests and reports as may be rbquired by the local health de-partment to be
made andiurnished by the applicant or by the locdl health department for purpose of the evalual.iun u[
the upplicutiurr; ancl tlic issuincc of thc pbrrnit ic subiect to such terms and conditions as dcemed
neceisary to insure compliance with rulds and regulations made, information and.reports submitted
herewith and required td be submitted by the applicant are or will be rep.resented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatin[ the same for purposes of issuing the. permit a.pplie.d for herein. I
fuither understand that anyfalsifiiation or misre'presentation may result in the denialof the
application or revocation of any permit granted bbsed upon said application and legal action for perjury
as provided by law.
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Special Conditions:
Pcrmit Fpe:un.oo Total Fees:(dT)oo Fees Paid:(d(T).oo
Building Permit OWTS Permit:swr-qab lssue Date:Balance Due:+
Garfield County Public Health Department:
Signed Approval Date
Gar"field County Public Healih Department - working to promote health and pretrent disease