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L95 w. 14th street
Rifle, CO 8L650
(970) 62s-s2oo
Public Heulth
20L4 Blake Avenue
Glenwood Springs, CO 81601-
(970)94s-661-4
OWTS PERM IT APPLICATION
Phone:
MailingAddress:50eo (o ad ,çLt 6len wutl .çpìnlç lo
Email Address:Ka a[pyttttur,¡lln K,iltrìch ú(14. Þh4
Gaffield County
TYPE OF SYSTEM CONSTRUCTION
lruew lnstallation E Alteration tr Repair
,BUILDING
USAGE TYPE
Dwelling E Transient Use tr Comm./lndustrial n Non-Domestic
E Other Describe
INVOLVED PARTIES
ìi+llre e
Property
Email Address:
Mailing Address:
ra
Contractor:
MailingAddress:
Email Address:
I
PROJECT TOCATION AND
Was an effort made to connect to the Community Sewer System:
Job Address:
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AAI þ,J brtrwil bt i3-qtoct<Assesso/s Parcel Num
Ga rbageDisposatlY$l PD
" Ztz1T6?dOO8?
Distance to Nearest Community SewerSystem:
Building or Service
p Cisternp well E Spring D Stream or creek
E Community Water System Name
Potable Water Source
& Type
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.
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I hereby acknowledge that I have read and understand the Not¡ce 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 Date
oFF¡c¡AL usE oNLY ?A lD , I tZg ,oc C. e. Og I oS /zo ?2 áP
Special Conditions:
Permit Fee:.ltz3.oô
Total Fees:I l¿3.ôo
Fees Paid:f lz3.oo
Building Permit
Buge '1Soq
OWTS Permit:
sePr, ?5 lô
lssue Date:Balance Due:+l
Garfield County Public Health Department.
Signed Approval Date
05/20/2022