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L95 W. 14th Street
Rifle, CO 8L650
(e70) 62s-
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 8L601
(9701 94s-66t4'w
OWTS PERM IT APPLICATION
Gaffield County
TYPE OF SYSTEM CONSTRUCTION
Q New lnstallation tr Alteration tr Repair
BUILDING USAGE TYPE
E Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
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Email Address:
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Mailing Address:24lz 0ro¡nol
Property
Contractor: Phone: ( Q+o ) ctS*-f832
Email Address: S"". År, ¿UC e qrñ^.r\ r Corn
Mailing Address:
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EmailAddress:
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PROJECT LOCATION AND DESCRIPTION
BuildingorServiceTyp"'l4o,.n.¡Q..Iv,.cÁ $pwrå *Bedrooms: 3 GarbageDisposal(Y/N)
Was an effort made to connect to the Community Sewer System:
Assesso/s Parcel
Distance to Nearest Community Sewer System:
Job Address:
Sub. (r¡,\dc/r e.ard¿n( Lot ÞZ glock-
E Stream or Creek E Cisterntr Well tr SpringPotable Water Source
& Type Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon suclt [urther
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 issr.lance of the permit is srrbject to srrch terms and conrlitions 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.
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 Pri Date
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Special Cond¡t¡ons:
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Buildine Permit
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OWTS Permit:
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lssue Date Balance Due:&
Garfield County Public Health Department:
Signed Approval Dâte
05/16/2023