HomeMy WebLinkAboutApplication-PendingPublic Hea Ith
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Garfietd County Fublio lt-fealth Department - working to promote health and prevent disease
Rpplicant acknowledges that the completeness of the aoolication is conditional upon such further
mandatory and additionaltests and rdports as may be r'ebuired by the local heahh department to be
made and furnished by the applicant or bv the loc6l health deparfment for purpose of the evaluation of
the application; and the issuance of the oirmit is subiect to srich terms and conditions as deemed
neceSsary to insure compliance with rulis and resulaiions made, information and reports submitted
nerewith and required to be submitted bv the ao'olicant are or rniill be represented to be true and
correct to the best of my knowledge and belief inA are desisned to be r6lied on by the local
department of health in.evaluatinf the same ioi purposes oT isiuing the permit applje.d for herein. I
fufther understand that any falsifiiation or misrebreientation mav-resuli in the d'enial of the
application.or revocation of any permit granted based upon said application and legal action for periury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certlfication above as
well as have provlded the requlred lnformatlon whlch is corect and accurate to the bst ot
my knowledge.
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Owner Print and Slgn Date
Speclal Condltions:
Fee:@ Total Fees:oo Pald:oo
Bullding Permlt OWTS Permit:lssue Dete:SaleneDue:
Slgned Approval Data
Garfield County Publlc Health Oepartment:
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