HomeMy WebLinkAboutApplicationGarficld County
Lgs w- i.4thstreet
R!fie, CO 8L650
{970} 625-52,0CI
Public Heulth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Gfienwood Springs, CO 81601
(970) 94s-6614
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PropertvOwnec Stepfrcm amd $usamrre Setlf Phone:{ 970 1274'0f6'4
illailingAddruss: tr09E CounW Road 2114, Sdilt, CO 81652
Gmail Address: stepfrnern@wii{dca$fisp.fi}et
{ontr*br:-fiBD See ist of comtrac.tors to to he mrntac$ed Ptrore:
MafigAddress:
EendlAddrers:
Deric \ €it{er. tsoumdaries ll,Jmlinnited LLC Phone:(szo 1945-5252
MafmgAddrces:923 Cooper Ave. Sb 201, Gibn\6/ood , co 811601
fnrdl Addless: Denic@tnl-inc.conn
PMICCT IOCANOil AilD IIESIMPNON
.lobAddrcss:tlffi County R,ooad 214, Srilt, CO 8'i1652
Assesso/s Parcel 217,03f.00.006 Antlerr,Orcilard hTrac,t t Block _
Suilding or Servie TWe: Pnivate Dwdlll'inq #sdroorm: 6 Gartage Disposal(Y/Nl J__
Disanoeto ltearcet Community Sewer Sy:tem:2lMliles applrox
Was an e{fort made to conn€ct to dp Community Seurv Sptem:lNko
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Garfield County Public Health Department - working to promote health and prevent disease
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I hereby acknowledge that I have read and understand the Notice and Certification above as
wetl as have prwided th€ required information which is correct and accurate to the best of
my knowledge.
$teptlenr and Sursanne Self July 8,2O24
Propertt Ouner Print and Date
Appldgant ackmowfledges that the completeness of the application is conditional upon such further
rmandatony-arnd additr"omail tests and reports as may be reiluired by the local health department to be
n'nade and filrnished by the applicant or by the locdl healtli departhent for purpose of the evaluation of
the applicatiom; and the issuance of the permit is subject to srich terms and conditions as deemed
necessaf,Y to insure corrnpliance with rules and regulations made, information and reports submitted
herewith and required to he submitted by the applicant are or will be represented td be true and
correct to the hest of rrrny knowledge and belief and are designed to be relied on by the local
departrmernt of hea[th t'n evaluating the same for purposes oI issuing the permit applied for herein. I
f,r.lrther underrstand that any falsification or misrepresentation may-result in the d'enial of the
applicatfrorrn or revoctt,ion of any pcrmit granted b-ased upon said alplication and legal action for perjury
as pnovided by !aw.
(FFISALT'SEOilLY I (
Sperial Comfftirr:
PenrnitFo:Gw.cc,Total Facs:(oo,c'c/Fees Paid:(ooO
AsildiqgFemit OIflTS Permit:
5ET{-84at^
lssue Date:Balance Due:
GarfieH Caunty Fublk Health ltepartment:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
08/07/2024
08/07/2024