HomeMy WebLinkAboutApplication-PendingL95 W. l-4th Street
Rifle, CO 81"650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO
81601
(970\94s-66L4Fwfpf ic Hea{tf,s
OWTS PERM IT APPLICATION
Gurfteld County
TYPE OF SYSTEM CONSTRUCTION
BUITDING USAGE WPE
Major Repair I Minor Repair [] Alteration n Vault and Haul
E Transient Use E Cornm./lndustrial
Phone:
'L c
INVOTVED PARTIES
Property Own
Mailing Address
EmailAddress:
New lnstallation
Dwelling E Non-Domestic
E Other Describe
Phone:Contractor: ff lhlrd r 5p.,oh c
Mailing Address:
EmailAddress:
;r0'la I
Was an effort made to connect to the Community Sewer System
Phone:Q'to| \04-ft19
z a
n
I ttlNumber
Building or Service Type
Distance to Nearest Commu Sewer
rooms: {
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PROJECT LOCATION AND DESCRIPTION
Mailing Address
EmailAddress:fl'rln . n<l-lrr ro O. am o,l Cs{ /l
Project Address:
Assessor's Parcel
-I \
n Well I Spring I Stream or
Creek
I Cistern
ln Vlo^ l[,O
Potable Water
Source & Type
Community Water System Name
*artiel* C*txtty {?t:lslic ?4aall* *epa*rnenl - warkin,S la pra**t* l:**,'1* and prevat* di**as*
CERTIFICATION
pplicant acknowledges that the completeness of the application is conditional upon such
rther mandatory and additional tests and reports as may be required by the local health
epartment to be made and furnished by the applicant or by the local health department for
urpose of the evaluation of the application; and the issuance of the permit is subject to such
rms and conditions as deemed necessary to insure compliance with rules and regulations
ade, information and reports submitted herewith and required to be submitted by the
pplicant are or will be represented to be true and correct to the best of my knowledge and
elief and are designed to be relied on by the local department of health in evaluating the same
r purposes of issuing the permit applied for herein. I further understand that any falsification
r misrepresentation may result in the denial of the application or revocation of any permit
nted 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
wellas have provided
my knowledge.
the required i which is correct and accurate to the best of
1 L L
Property Owner and Date
OFFICIAT USE ONLY a,
Special Conditions:
Permit ree: ( OOr+1 OO Total Fees: (ffi p Fees Paid: l,gi @
owrs eermiffiQl |fi$e oate:Balance Due: n'uBuilding Permit
Garfield County Public Health Department:
DateSigned Approval
Gartield Cau*ly ?ublic t4*allh nspa{t{nonl * utarking t"* prarn*Ie hoall?s anrl pr*ver$ dis*a*o