HomeMy WebLinkAboutApplication-PendingGurfteld County
195 w. l-4th Street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
WPE OF SYSTEM CONSTRUCTION
n Minor Repair E Alteration E Vault and Haul
BUITDING USAGE WPE
I Transient Use Non-Domestic
I Other Describe
2014 Blake Avenue
Glenwood Springs, CO 81601
(970\94s-6614
E New lnstallation n vajor Repair
tr Dwell Comm./lndustrialtr
INVOTVED PARTIES
Building or Service Type: Mtw #3"6
Was an effort made to connect to the Community Sewer System
Garbage Disposal(Y/N)_
ne
Assessor's Parcel Nu
Property
Distance to Nearest Community Sewer System:
Mailing
Job Address:
roo
PROJECT TOCATION AN D DESCRIPTION
Co
Email Address:
Mailing Address
EmailAddress:
Mailing Address
Email Address:
S wett tr Spring E stream or Creek E CisternPotable Water Source
& Type n Community Water System Name
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
niandatoryand addiiionaltests and rdports as may be required bythe local health de-partmentto.be
made and furnished by the applicant oi by the local health department for purpose of the evaluation of
the application; and tlie issuince of the pbrmit is su.bject to such terms and conditions as deemed
neceisary to iniure compliance with rul6s and regulations made, information and.reports submitted
herewith'and required td be submitted by the applicant are or will be rep.res.ented to be true and
correct to the beit 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 a,pplied for herein' I
fuither understand that any falsifiiation 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 Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge
J c PnPe 7- t,- zf
Property Owner Print Date
OFFICIAL USE ONLY \
I
Special Conditions:
Permit Fee:
tcOo I oo Total Fees:bN.co Fees Paid oG.6 I
Building Permit?rIE ?ZSg
OWTS Permit:
TEPT/q2S-I
lssue Date:Balance Due:
-*
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease