HomeMy WebLinkAboutApplicationGø,rfield Çounty
rgs w, t4th street
Rlfle, CO 81650
(e7o) 62s-5200
I'wblÍe Heallh
otfrtT$ pËRMIT AFPTICATION
2014 Blake Avenue
Glenwood $prings, CO 81601
(e70) 94s-6614
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E Alteratlon tr RepairNew lnstallation
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Bulldtng or servhe rype: f€ l, d9+ti¿, \ .... *sedrooms: 5 Garbage DisposallY/nl Y
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Di¡tance to Neðrest Community Seurar System:
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Asseseo/s Farcel
Ãwell tr $prlng E Streamorcreek E cl¡trrnPotable Water Source
&Type E Communlty Water Syst€m Nåmo
Clarfiekl County Pr¡blic Health Departmant -'working to pronrote lrealth ond prêvent dieease
Aoolicant acknow{edges that the completeness ef the,apBliçetig¡ isconditional upon such firrther
;iJrääåiü;iä'åäortiıñrlteiilãnà réports äs mây be r'ebulred by the local health department t0 bë
;üääåi;;;irî;îïi'iïäãi,ËlËåiiäiij'iiñã iôðár r,ãattiîàepartment ror purpo.se of the evaluation or
üi;;ñìñ;til; |id iÉ" ffå'i¿;ïihu färmit is su.b¡ect to stich terms and conditions as deemed
f,åiiirnhilålä:itiÏr:i'xlniifit[:.;;ruT'iål'ii'ïËïl;l''"åirilTsfï'ifs"å'"0
correcr to the best or rîrir,-ovJËäääã;d 'bålËiåñd ãrä oãsignea to be rólied on bv the.local
ı;;,fi;i;lr'ìàir' ¡"Liäiriå't¡'.rãir'Ë årne ror purposes oI issurng thei.,int å:fi:iüïierern'
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Írìt¡'o ú;ï;iståñ¿ t¡'at any falsifiãation or misrepresentation qay rqi
;Ëp'iüåtffi;iä*ät¡"'n äi;;t p;¡ñlt sianteã
-¡àsã¿ upon said application and legal action for perjurv
as provided by law.
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I hereby acknowledge that I have read and understand the Not¡ce and Ceniflcat¡on above as
well as have provlded tùe requJred lnfometlon Ìvhlch ß correct and accuretÞ to thê tÞs't of
my knowledge,
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Garfleld County Publlc Health Departm€nt:
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