HomeMy WebLinkAboutApplication-SignedGarfield County Public Health Department working to promote health and prevent disease
195 W. 14
th
Street Rifle, CO
81650
(970) 625-5200
2014 Blake Avenue
Glenwood Springs,
CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New
Installation
Major Repair Minor Repair Alteration Vault and Haul
BUILDING USAGE TYPE
Dwelling Transient Use Comm./Industrial Non -Domestic
Other Describe
INVOLVEDPARTIES
PropertyOwner: Phone:( )
MailingAddress: _
Email Address:
Contractor: Phone:( )
Mailing Address:
Email Address:
Engineer: Phone:( )
Mailing Address:
Email Address:
PROJECTLOCATION ANDDESCRIPTION
Project Address:
Assessors Parcel Number:Sub. Lot Block
Building or Service Type: #Bedrooms: GarbageDisposal(Y/N)
Distance to Nearest Community Sewer System:
Wasan effortmadetoconnect totheCommunitySewer System:
PotableWater
Source & Type
Well Spring Stream or
Creek
Cistern
Community Water SystemName
Public Health
Oil and Gas Location - Small Temporary Housing
Chevron U.S.A. Inc.
760 Horizon Drive, Suite 401, Grand Junction, CO 81506
tracey.fallang@chevron.com
Chevron U.S.A. Inc.
760 Horizon Drive, Suite 401, Grand Junction, CO 81506
tracey.fallang@chevron.com
Sterling Walker
85 S 200 E, Vernal, UT, 84078
swalker@uintahgroup.com
SKR 698-10-BV Well Pad
2137-321-00-008
SETH 6-8
N/A
N/A
City of Rifle, Town of Parachute, Town of Meeker
970 304-5000
N
970 304-5000
435 789-1017
Garfield County Public Health Department working to promote health and prevent disease
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.
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Total Fees: Fees Paid:
Building Permit OWTS Permit: Issue Date: Balance Due:
Garfield County Public Health Department:
Signed Approval Date
3/23/26Tracey Fallang Digitally signed by Tracey Fallang
Date: 2026.03.23 11:31:15 -06'00'
4/13/26
4/13/26