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195 w. t4th Streelt
Rifle, CO 81650 -
(970) 62s-s2oo I
Public Heulth
2014 Blake Avenue
Glenwood Springs, CO 81501
(970\ 94s-661.4
OWTS PERMIT APPLICATION
Garfield County Public Health Department - working to promote health and prevent disease
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Guffield County
TYPE OF SYSTEM CONSTRUCTION
N New lnstallation tr Alteration tr Repair
BUITDING USAGE WPE
n Dwelling E Transient Use ! Comm./lndustrial tr Non-Domestic
! Other Describe
INVOLVED PARTIES
Property Owner: rtvnt <o v^-cil\ ct A L4 <rbzratlo Vgu Phone:
MailingAddresst ?{c2c",v-A V fo*.L l?--t d*2 -ale*.,wwbb fl€,r\ut{, C.vl$ Sl|dq
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*l \Email Address
Contractor one:
MailingAddress
EmailAddress:
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Mailing Address: ll/ t**$
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PROJECT LOCATION AND DESCRIPTION
Engineer
EmailAddress:
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4'20
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Assessor's Parcel Number:$ ! f.]t38Ia*3FC sub. .5eu\\+* J-e,nL I-ot-f-alock-
Was an effort made to connect to the Community Sewer System:
Job Address:e4
Distance to Nearest Community Sewer System:
Building or Service GarbageDisposal(Y/N) y6
s e f'+!c
ui I #Bedrooms: ?
D Cisternfr wett n Spring n Stream or CreekPotable Water Source
& Type n Community Water System Name
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.
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.
Property owner Prlnt and
4-2q -3-1
Date
I 6-4OFFICIAL USE ONLY \
Special Conditions:
Permit Fee:(ooo I Total Fees:
( rrd),&(oOo,Fees Paid:d
Building Permit
trt[.,tr-fl6a
OWTS Permitffi[f-grls?;lssue Date:Balance Due
Garfield County Public Health Department:
Signed Approval Date
'.':.:, , | '
05/24/2024