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Public Heulth
195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970)94s-6614
OWTS PERM IT APPLICATION
OF SYSTEM CONSTRUCTION
Gaffield Coun$
E Minor Repair E Alteration E Vault and HaulN New lnstallation E Major Repair
BUILDING USAGE WPE
tr Non-Domestictr Comm./lndustrialN Dwelling El Transient Use
fl Other Describe
INVOTVED PARTIES
Email Address:ot
Property
Mailing
Mailing Address:
Email Address:
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Mailing Address:
EmailAddress:
WasaneffortmadetoconnecttotheCommunitySewerSystem:
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Assessor's Parcel
Building or Service
PROJECT LOCATION AND DESCRIPTION
Job Address
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Distance to Nearest Community Sewer System:
E Cisternd wett tr Spring E Stream or Creek
unity water system tlame \N rvr t( r Pa54ur.r \ lCltf/ *5 (dC'E Comm
Potable 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 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 t6 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 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.
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certiflcatlon above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.O l3a G|;t,ei/o"4 6- i6-x
Property Owner Print and Slgn Date
oFFtcrAt usE \
Speclal Conditions:
-m,@)*"U:bp,@Perrnit Fee:(eo,q)
OWTS P€rmit:gl'fifq+1K lssue Date:Bala49{ueWZE%+
Garfield County Public H€alth Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease