HomeMy WebLinkAboutApplication-Pending; p . ;_:jvf:ft
fi.: ', /r .,.!ri"-.!rr:, /-{ ill!l.t
GA.-.d"J COLJ
Ctliri;.:i:i:itJy fi[VELOPME
195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 8150L
(970l,94s-66L4
OWTS PERMIT APPLICATION
Garfteld County
TYPE OF SYSTEM CONSTRUCTION
E Vault and HaulE Minor Repair rationE Major Repairtr New lnstallation
ILDING USAGE TYPE
tr Non-Domestictr Comm./lndustrialE Transient UseDwelli
E Other Describe
INVOTVED PARTIES
6o 9lG
{1a
I
bozek*^tsk t.a\
Property Owner:
EmailAddress:
Mailing
rw^: [. Cortzr
?47 04
(ne e:
o
. Coutzl(L
Mailing Address:
Email Address:
t3{1 C-e zq
{
Mailing Address:
Email Address:
Building or Service Type: fBedrooms: ?- Garbage Disposal(Y/N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System
D DESCRIPTION
oYmo BlockAssessor's Parcel N
PROJECT TOCATION
Job Address:
El CisternE Stream or Creekfretttr Spring
EI Community Water System Name
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.conditio.nal upon such further
niandatory and addit-ional tests and rdports as may be required by the local health derfrartment to be
made and furnished by the applicant oi by the locil health department for purpose of the evaluation of
the application; and tlie issudrice of the pbrmit is su.bjectto such terms and conditions as deemed
neceisary to iniure compliance with rultls arrd regulal.ions tttade, ittforntation and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be represented to be true and
correct to the belt 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.pplie.d lor herein. I
further understand that anyfalsifiiation 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 kn
+/",1-
Property Owner Print and Sign Date
L*r( r
OFFICIAL USE ONLY
Special Conditions:
Total Fees:
Aoo .oo
Fees Paid oo8@Permit Fee oo,Qocl
Balance Due:+OWTS Permit:sErqrqo lssue Date:Buildine Permit
Rt[uQ5gR
Garfield County Public Health Department
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease