HomeMy WebLinkAboutApplicationGarrteW County
Public Health
195 W. 14ú street
Rifle, CO 81650
(970) 625-s2oo
2014 Blake Avenue
Glenwood Springs, CO 81601
{e70) e4s-6614
OWTS PER MIT APPLICATION
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E Oth€r Describe
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PNdECT TOCATION ANÐ T}ESCRIPTIOT{
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Garfield County public Health Department - working to promote health and prevent disease
CERTIFICATION
Aoolicant acknowledges that the completeness of the application is conditional upo¡r such further
nìandatorv and additíonal tests and reports äö.È;*qüi*ïÈi tt'" local health department to be
made and'furnished by the applicant or UV tËã [iä f,ãà1t1, äup"ttmäñt iıi purpos" of the evaluation of
the apprication; and tlí,;i;ilJ,ü;ãïir,q pårrn-¡t'i,î;Ëj'äñ r-ü.h terrns and'cond¡tions as deemed
necessary to insure "å;i,tñ;;ü,¡*, ir-r,ir ;ä;ä"l;iıñi ma¿e,.iñiotmàt¡on and reports submitted
herewith and requireäi5'Ë'r"äu*ìüàd bi tiËıiï¡änt àrä ri*iti6à repr"sented to be true and
correct to the best of my knowledge.and U"ìiåiåñJ äiä designed to be ràl¡ed on bv the local
ö;.ü;;i ãir.,ããrilì ¡ä'.üaiuåtinãÚ,. '"'ä-rolilı;;:iii'aiil¡5gfrtffir',f,11ïherein'
r
il#ñLi';;å;;itäiä îr, åi i ni ta ¡ s¡ r'r-cati o n o r misrepre se ntati o n m a
aoorication or revocation of any permit gr"Åiåäiãî*I;Ëï;iäã'ppti.àtion and regal action for perjury
aiþrovided bY law.
I hereby acknowledge that I have read and understand the Notice and certificat¡on above as
well as have provided the required informationwhich is correct and accurate to the best of
my knowledge.
Property Owner Print Sign Date
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Spcclal Condltions:
Fees P¡ld:
4 tz3. ôoTot¡l Fees:
I (zg.noôoFce:Perm¡tt¡L
Ealancc Due:
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b8uc D!tc:OWTS Permlt:
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Bulldlng Permit
cüf¡cld county Public }l3slth D€ptftmÇRt:
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