HomeMy WebLinkAboutApplicationGurfteld County
195 w. 14th street
Rifle, CO 81650
(e70) 62s-s200
Publíc Health
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
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WPE OF SYSTEM CONSTRUCTION
El New lnstallation tr Alteration tr tr
E Dwel E Transient Use
BUILÐING USAGE WPE
tr Comm./lndustrial n Non-Domestic
I Other Describe
INVOTVED PARTIES
MailingAddress: P.Ò, 6oY- tÐ8n, órLr¡ C-o. 8tþ6J
EmailAddress: ÈÈ Tl*¡cçsru&t @ \t¡tstnn¡¡rU.Corh
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Mailing Address: P,o. P,.:P ¿è
EmailAddress: ët:çØ. &¿çX Ô'¡(to<rtL' C<tnq" "
engineer: F¡ly tt Cou¡.¡ttl*{ EÂ) (zcO€ÉÈç¡rlG, ¡¡rC Phone:
Was an effort made to connect to the Community Sewer System: ¡' o
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PROJECT TOCATION AND DESCRIPTION
Job Address:
Distance to Nearest Commun¡ty SewerSystem:
Building or Service rtLE
MailingAddress:
EmailAddress:
5Të.
El well tr Spring E Stream orCreek E CisternPotable Water Source
& Type D Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the åpplication 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 regulatíons 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 falsificatíon 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.
CERT¡FICATION
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.
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Property Owner Print and Sign o Date
OFFICIAL USE ONIY ?á 4 tz3Po cc o7 /74 /zort ¿Þ
Special Conditions:
Perm¡t Fee!
+ t\3Y Total Feesl! tz3.oo
Fees Paid:* tz3.æ
Bulldlng Permlt
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OWTS Perm¡t:
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lssue Date:Balance Due:iÉ
Garfield County Public Health Department:
Signed Approval Dãte
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