HomeMy WebLinkAboutApplication-Pending195 W. 14"' Street 2014 Blake Avenue
Gatfield Counlyenw od Springs. CO 81601
Rifle, CO 81650 _ (970) 945-6614
(970) 625-5200 -
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION !!--
❑ New ❑ Major Repair IlYnninor Repair ❑ Alteration ❑ Vault and Haul
Installation
BUILDING USAGE TYPE
n b ❑ Transient Use O Coin in. /Industrial O Nun -Domestic
VOther Describe 41y nn onNJyudr_LL_veJ-_
INVOLVED PARTIES I
Property Owner. i bL1��'1-__._ .._._� Phone:
i+13ti1SinK Address:
l 1�
I
Email Address:
Contractor: Phone:I I_
Mailing Address:
Email Address:
Engineer:_ _Ca • Phone: M U — :a 1 c ' 1
Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
1
Project Address: _
F r�
Assessors Parcel Number: ;I$C.�
Building or Service Type: [� y�[ � _ asedrooms: J Garbage Disposal(Y/N)_
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water LP�eli ❑ Spring I J Stream or, Creek ❑ Cistem
Source & Type O Community Water System Name
f71"p11,!_I!1-fI[:,liV i'{!„'+SIC i'ie" PI �.%'1'��' Ir', •I' i,•, --i 11;(; !,i p!ell: �1- 1111'.1ond pIx-'JI=I;I 'i<-
CERTIFICATION
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.
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.
George Williamson./ _ _
Property Owner Print and Sign
OFMAL USE ONLY
10/27/2025
Date
Special Conditions:
Permit Fee: Total Fees: 2.00 Fees Paid-
O Ci
Bu ding Permit OWTS Permit; Issue Date: Balance Due:
Garfield County Public Health Department:
Signed Approval Date
�. i ,..'�`; l!irlil i'.�.,lii ;•j�:.rllili , R�i�`I' 1i';-�rk�ltti� Ic ;;rr�n~r,,�a h?cHa�'.I+:1i1{- j`, .., 'I). ^!S;. .l`;r.