HomeMy WebLinkAboutApplication-PendingDocusign Envelope ID: 3510ED89-EE93-869C-81A2-EB7694B29A28
195 W.14`h Street
Rifle, CO 81650
W°ff
Gar eld County
-i
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)945-6614
MAP 0b 2026 OWTS PERMIT APPLICATION
GARFIELD COUNTY
COMMIIhATMPEWMeM CONSTRUCTION
1 R. New Installation ❑ Major Repair ❑ Minor Repair ❑ Alteration ❑ Vault and Haul
BUILDING USAGE TYPE
Dwelling ❑ Transient Use _ j ❑ Comm./industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property owner:_`
Mailing Address -,—
Email Address:
Contractor:n
Mailing Address: _
Email Address:
Engineer. C' 6Q
ie e-Ps . c_o7n
e. phone:i 1
cc) g/G SD
�� Phone 9 � -11
Mailing Address:
Email Address: G.,%r lGt • 05�berg ZL ylLJ
1 PRO ECT LOCAT-eN AN_D DESC[tl ON
Job Address: _ 5'3 1 G�+
Assessor's Parcel Number: 121750)-M12.SUb. e�-I r �O Lot i Block
Y i Building or Service Type: �; � Ie�P s - nedroorns: Garbage Disposalt;Y/N) �L)a
Distance to Nearest Community Sewer System: lv"n m't` i°
Was an effort made to connect to the Community Sewer System: A)O
Potable Water Source }'- Well ❑ Spring ❑ Stream or Creek ❑ Cistern
& Type ❑ Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Docusign Envelope ID: 3510ED89-EE93-869C-81A2-EB7694B29A26
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.
Harold Stevenson vice -President 46 March 5, 2026
Property Owner Print and Sign
Date
OFFICIAL USE ONLY �
Special Conditions:
Permit Fee:
Total Fees:
Fees Paid:
00
lQco 00
COD
C"
Building Permit
L Pe
Issue Date:
Balance Due:
Srmit�
Garfield County Public Health Department:
Signed Approval
Date
Garfield County Public Health Department — working to promote health and prevent disease