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Public Health
195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(97O) s4s-6614
OWTS PERM IT APPLICATION
Gaffield County
\TYPE OF SYSTEM CONSTRUCTTON
AL ruew lnstallation ! Major Repair E Minor Repair fl Alteration E Vault and Haul
BUILDING USAGE TYPE
E Dwelling n Transient Use tr Comm./lndustrial n Non-Domestic
E Other Describe
INVOLVED PARTIES
Phone:('-I-fo \sf"l ' ltlDProperty Owner:
o(d-mr"r'r"It
Mailing
teF K{6?-tAddress:4o{ mVab,g.rv (PwlzT BA.
Email Address: W&Cn
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Mailing Address
Email Addressl
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address: lZ9 Cn tNJ LA Ntr CAe-B6t11p7npLE , LB 9 /AtE
Phone: (-l-to 1 <O'i .5Lb1
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Engineer:
Mailing
(_v o t t^.rr_,
Email Address: (A
PROJECT LOCATION AND DESCRIPTION
JobAddress: 6'C € lAl ODVEN 1''2,P,l|-14.'.-..
Was an effort made to connect to the Community Sewer System A/D
Distance to Nearest Community Sewer System
Assessor's
Building or
t CAQ:t3op}.hLE lrh uvt r t PA L,
n Well E Spring E Stream or Creek ! cisternPotable Water Source
& Type ,E( Community 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 additionaltests and reports as rnay be required bythe 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 subjectto 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 anyfalsification 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.
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Property Owner Print and Sign Date
'FFTCIALU'E'NLY ?a: "\(#
qMo
Special Conditions:
Permit Fee:
IrrXl F &IffiTotal Fees:Fees Paid:
boa oo
lssue Date:Balance Due:,+Building Permit
?.r A.E-q3"b
oWTS Permit:sPr43a+
Garfield County Public Health Department:
Signed Approval Date
Gar-field County Public Health Department - working to promote health and prevent disease