HomeMy WebLinkAboutApplication-Pending195 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
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2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-6674
OWTS PER MITAP PLICATION
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EI Dwelli tr Comm ustrial Non-DomestictrE Other Describe
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Property
Email Address:
Mailing
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Mailing Address:
Email Address:
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TOCATIONAIIID
Mailing Address:
Email Address:
Was an effort made to connect to the Community Sewer System:
#Bedrooms: Z- Garbage Disposal(y/Ny'
Assessor,s parcel Nu zt
Distance to Nearest Community Sewer System:
Job Address:
Building or Service TVpe: kSrD'Lutl ttt-
E well tr Spring E Stream or Oeek E CisternPotable WaterSource
& Type E Community Water System Name
Garfi*ld ccunty F*blic l-l*elth sep*rtment * working to promot* h*alth end prev*nt dis*ass
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 td 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 resuli in the dehlal of the
application.or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby
well as have
that I have read and understand the Notice and Certification above as
the required information which is correct and accurate to the best of
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Property Print and Sign Date
Speclal Conditions:
Permit Fee:(,<xl .oc)Total Fees:
( dY\,oe)@Fees Paid:(ffi
Buifding Permit2r0hq(9K OWTSRermit:4Fl\.q7fp..lssue Date:aatanceD$*
Garfield Counry Public Health Department:
SignedApproval Date
Garfield County Fublic Health Departm*nt * w*rking to pramote h*alth and pr*vent disease