HomeMy WebLinkAboutApplicaiton-Pending195 W. 14th Street
Rifle, CO 81650
(e7o) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
201"4 Blake Avenue
Glenwood Springs, CO 81601
(970)e4s-661.4
Garfield County
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation E Major Repair E Minor Repair I Alteration E Vault and Haul
BUILDING USAGE TYPE
EL Dwelling E Transient Use tr Comm./lndustrial n Non-Domestic
E Other Describe
INVOTVED PARTIES
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Property
Mailing Address
Email Address:
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Contractor:
Mailing Address
Email Address:
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Mailing Address
Email Address:
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PROJECT TOCATION AND DESCRIPTION
Was an effort made to connect to the Community Sewer System:
GarbageDisposal(Y/N) Y#Bedrooms:
Distance to Nearest Community Sewer Syste m: tt/(\
Building or Service Type , z*ol1c'
Job Address:
Assessor's Parcel Number: A\\52,5-fu14 su
n Cisternfr wett tr Spring ! Stream or CreekPotable Water Source
& Type I 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
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.
CERTIFICATION
t 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
OFFICIAT USE
Special Conditions:
Permit Fee:b(Y.oo Total Fees .ooLffi Fees Paid;oo(rffi
Building Permit?ild-Q\or
OWTS Permit:
SEPI4e{ob-
lssue Date Ealance Due:4
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Depa(ment - working to promote health and prevent disease