HomeMy WebLinkAboutApplicationDocusign Envelope lD: 921 FF32B-F26C46D2-A4EA-4AB2F3CE770F
195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
WPE OFSYSTEM CO
BUILDING USAGEWPE
Property
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OWTS PERM IT APPLICATION
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2014 BlakeAvenue
Glenwood Springs, C0 81601
(s70) e4s-6614
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Buildlng or Sewice rJ 4Q wl 3 arbage Pisposal(Y/N) Y
Distance to Near€st Community Sewer System:UF tto'-t:P
Was an effort made to connect to the Community Sewer System rJa
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El Community Water system Name
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Garfield County Public Heslth Departmeril - working to pnrmote health and prevent disease
Docusign Envelope lD: 921 FF328-F26C46D2-A4EA-4AB2F3CE770F
Applicant acknowledges that the completeness of the application isconditional upon such further
niandatory and addit'lonal tests and reports as may be required by the local health dernartment to be
made and furnished by the applicant o'r by the locdl health department for purpose of the evaluation of
the application; and the issuince of the permit is subject to such terms and conditions as deemed
neceis'ary to insure compliance with rul6s and regulations made, information and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be represented to be true and
correct to the beit 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.
CERTIFICATION
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.
Harold Stevenson, Vice President i't't'r[1:
Property Owner Print and Sign Date
OFFICIAL USE ONIV I ,J
Special Conditions:
Permit Fee:
( nOC5.ou
Total Fees:
LaOO ,
oo Fees Paid:oo( ^c)3Buiiline Permit
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OWTS Permit:
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lssue Date:Balance Due:v
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Deparlment --working to promote health and prevent ciisease
08/09/2024
08/09/2024