HomeMy WebLinkAboutApplicationGørfreld County
ll-95\M. 14rr'street
lRrilflke, CO 81650
(e70))62s-s200
Puhlic Health
OWTS PERMIT APPLICATION
20114 Blake Avenue
Glenwood Spriings, CO 81601
(970) 94s-6614
Dwelling
TTNE OF
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I Transient Use n Comm.flndustrial fl Non-Domesüic
USAGE
ffi Other Describe
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FrmilAddress:
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lühllngAddress: _
ffiAddress:
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Phone:
tÌrtrgAddress:
MAddress:
ANID DESCRIPÌION
.üdbåddress:
Mo¡'s parcet Numbe r: 211?Z1l-oZ - suu.
tffiryorService 3 Garbage DisposaÌlCY/NI
thnce to Nearest Community SewerSystem:75
Itbtr effort made to connect to the Community Sewer System:l/\\
I StreamorCreek ü c¡stern
B Communþ Water System Nãme
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Garfield County Public Health Department - vlorkrng to prorûotÉ rrealrh and prçvenl disease
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3 { 123. ÞTotal Fees:fiees Paid:*123. Ètê
ffi, ffr OWIS Permit:
5E PÎ-'?+5{lssue Date:iRalance Due:È.1
'Garßdd County Pr¡bllc Health Departm€nt:
SlgnedApprovat Date
Applica.nt acknowledges that the completeness of the application is cor¡dfit-o¡nal upon such furthermandatory-and additional tests and reports as may be räi¡uired by the locatllhealth department to be
made and furnished by tfre applicant or by the locål health department fon purpose oi the evaluation ofthe application; and ttie issuáñce of the pärmit ¡s subject to süitr ierms a'ndj'æåd¡tions as deemed
necess.?ry to insure compliance with rules and regulaiions made, infor¡natiiom and reports submittedherewith and require-d to-be submitted by the apþlicant are or w¡ll be repnesented td be true andcgrrect to the best of my knowledge and bel¡ef ànd are designed to be rölli¡ed on by the localdepartment of health in-evalu_atin[ the same for purposãs oi ¡siu¡ne tñ. ee'nnit "pþäeá
ror herein. Ifurther understand that any falsifìıation or misreþresentition máv-rut,¡f'[ ¡mr tf¡e dän¡al of the
application_or revocation of any permit granted bised uponsa¡¿ appl¡catiomãnO tegát actíon for perjury
as provided by law.
acknowledge that I have read and understand the Notice and Cerlification above as
provided the required information which is correct and aæ¡laÊe to the best of
Barbara CEO, Ryobj Foundation 4t18t2022
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05/09/2022