HomeMy WebLinkAboutApplication-PendingGarfield County
Public Heulth195 W. L4th Street
Rifle, CO 81650
(9701 62s-5200
2014 BlakeAvenue
Glenwood Springs, CO 81601
(970)94s-6614
OWTS PERM IT APPLICATION
WPE OF SYSTEM CONSTRUCflON
A New lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
\BUt[DtNG USAGE WPE
Dwell I Transient Use I Comm./lndustrial tr Non-Domestic
n Other Describe
INVOLVED PARTIES
f1 t\ x l+-Phone:Property
Email Address:
Mailing
e: t't'\t) tcatt1 Dq\q
Email Address:
Mailing Address:.RCq L-r.sF tht,nc, - Drr
Mailing Address:
EmailAdd
Was an effort made to connect to the Community Sewer System:
Disposal(Y/N) !
b-/
Garbage
PROJECT
Job Address
Distance to Nearest Communify Sewer System:
Assessor's Parcel N
Building or Service
E wetl tr Spring E Stream or Creek n cisternPotable Water Source
& Type Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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
(" - c,-7 oLn
Property Owner Print and Sign Date
(o",--
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 cohditions 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 td 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 d'ehialof the
application.or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
OFFICIAL USE \
Special Conditions:
Permit Fee:(ffi.oo Total Fees:boo .cro
Fees Paid:boo.@
Building Permit
9'|w_-qqg
OWTS Permit:
SEgrqScn
lssue Date:Balance Due:t
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease