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195W. 14lhStreet
Rifle, 0O 81650
{970} 625-s2oo
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2014 Blake Avenue
Glenwood Springs, CO 81601
(e70) s4s-6614
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LOCA ANDDESCR'PTION
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to Nearest Community Sewer Systcml
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CÊRTIFICATION
I hereby acknowledge that I have read and unde
well as have provlded the requlred information
knowledge.
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Owner Pr¡nt and S¡gn
to be true and
to be on by the local
issuing the
the a ls
be red by the
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terms
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a or will be
are
itions as deemed
and reports submitted
applied for herein. I
denial of the
of
m ay re in the
said n and legal action for perjury
Notlce and rtlflcation abovê as
and to the best of
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Date
OFFICIAT USE ONLY
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Garflcld County Publlc Herlth Departmentt
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