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COfuiMUNIÏY DEVELOPM
195 w. 14û Street
Rifle, CO 81650
{970f 62s-s200
Publíc Health
OWTS PERMI T APPLICAT¡ON
WPE OF SVSTEM CONSTRUCNON
New lnstallation tr Alteration
2014 Elake Avenue
Glenwood Sgrings, CO 81601
(970194s'66L4
BUILD¡NG USACEWPE
dowelling ,trtrans ient Use t Comm./lndustrial
[] other Describe
[-r¡,rvowÉot*PARTIES
Property
Mailing
Émail Address:
MallingÀddr€ss!
Email Address:
MailingAddress:
CmailAddress:
l Þno¡ECT TOCANON DESCRIPTION
Job Addre¡s:
A¡sestot's Parcel Nu
8uílding or Service TYPe oispcralfrNl-
Distance to Nearest Communlty SewerSystem:
WasaneffortmadctoGonnecttothcC.ommunltySewcrSystGm:
: E Sprlnt
I
E Strc¡morGrcck
Ò
Potable Water Source
& Type I
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t Communlty Watcr Systcm ll¡mc
Gørrteld County
Non-Domestic
E Oritcrn
Gafield County Public Health Department - working to promole health and prevent disease
Stlf^l1l-.l9,owlq{çes that the completeness of the application is conditional upon such furthermandarory and additional tests and reports as may be rbbuired by the local health department to bemaoe and lurnished by the applicant or by the locál health depar{ment for purpose of the evaluatiòn ofthe application; and tlie issuáice oiit'" óärm¡t ¡r ";ti;äi;;üÏ; ilrms an¿ conditions as deemed
l::!.::,|Y^lo jnsurg complìance.w¡th rules arrd regulaiions made, lnformàtlon an¿ rãpãrts submitted
TI_rynTq required to.be suþmitted by the apþlicant are or wíll be represented tó be true andcorred to the best ot my knowledge and belief and are designed to be rólied on bv the localdepartment or health in'evaruatffiir,é s-amËrä;p¡'ô;iä7iır;sih¿;;räîäbiïä?ìr here¡n. rfurther understand that any fals¡fiËai¡ıÀãi m¡sre'preieñtãt¡on mjv result in the denial of theapplication or revocation of any pe¡mii s;ånleã
-d;ËA;Ë;;äiääb'pìirjiiä;d tä;iäiä; for perjuryas provided by law.
CERTIFICATION
I hereby acknowledge that I have read and understand the t{otice and certiñcation above as
well as have provided the required information which ls correct and accurate to the best of
my knowledge.
Mar 1,2023
and Sign Date
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I ¡rrl,ilr,l I l{ r ll} I I
oFFlclALutr o","<èìA a Ò qs 1.!) -,JR.
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Special Condhions:
Permlt Fee:æ24 Total Fees:?s.o"Fees Paid:?€æ
Bullding Permlt
SEYI-?ff lssue Date¡EalanceOWTSPermlt:
Garñeld County Publlc Health Dep¡rtmeñt:
SlgnedApprorrl D¡te
03/14/2023