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APP LICATI
RECEIVED
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GARFIELD COUNTY
COMMUNIfi DEVELOPMENT
2O14 BlakeAvenue
Glenwood Springs, CO 81601
(970) 94s-6614
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,E Other Ðescribe
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PERMIT
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Ëmail Address:
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EmallAddres¡:
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Bulldlng or Sewice DtsposallY/Nt+-
Distence to Neafest community Sewer sysËem:
Was an effort madeto connecrre tte Community$ewerSystem:
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Gurficld CountY
El AlterationNew lnstallation
USAGEWPE Non-DomesticComm./lndustrialEl Tnnsient Use
-E qsternE StrermorCreektl SÞring
ComrnunitY ìlÛeter Systcm Name-&Type
Garfield County Public Health Ðepartment-working to promote health and prevent disease
I hereby acknowledge that I have read and understand the Notice and Certificat¡on above as
well as provided the required which is correct and accurate to the best of
my
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Property Owner Print Date
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additionaltests and reports as rnay be required by the local health department to be
made and furnished by the applicant or kry 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 falsifiıation or misrepresentat¡on 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.
oFFlclAL UsE ONLY PAI D f tz3. oo cK''r r'{68t 6t /t//¿ozz ¿-gaæ
Special Conditions:
Total Fees:f r 23.ôo
Fees Paid:4 r 23.æPerm¡t Fee:* ¡23.""
Balance Due:rølssue Date:Building Permit
Bur¿,€,-7:r8l
OWTS Pernit:
S€Pc- 119o
Signed Approval
Garfleld County Publ¡t Health Department¡
Date
Pag:5 c1-J,
I ;;,i]ritcr3 ìi:¿c iì{}l"i
06/23/2022
06/23/2022