HomeMy WebLinkAboutApplication-Pending''r "qD
jtJi{ J 0 ,f{in;
195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
20L4 Blake Avenue
Glenwood Springs, CO 81601
(970)94s-6614
OWTS PERM IT APPLICATION
I nt'
Gurfield County
WPE OF SYSTEM CONSTRUCNON
New lnstallation tl vajor Repair E Minor Repair E Alteration E Vault and Haul
.BUILDING USAGE WPE
7pr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
D Other Describe
INVOLVED
g t\
Property
Email Address:
Mailing
t-l I$ te5t1 Oult cl
Mailing Address:
Email Address:
Mailing Address:
Email Address:
PROJECT LOCATloIao![ D-]DESCR|PTTON
Was an effort made to connect to the Community Sewer System
Assessor's Parcel Number
Job Addresi:
Building or Service
Distance to Nearest Community Sewer System:
I Well E Spring E Stream or Creek n CisternPotable Water Source
& Type nity Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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 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.
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.
Property Owner Print Sign
OFFICIAL USE t tn
Special Conditions:
Permit Fee:(ffi,&)Total Fees:(&.@ Fees Paid:
I aOO,oo
BuildinE Permit(L).ilE qrc iffh4esr lssue Date:e.t.n.ff'
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease