HomeMy WebLinkAboutApplication-Pending11
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195 W. 14th Street
Rifle, C0 81650
(970) 62s-s200
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OWTS PERM IT APPLICATION
WPE OF SYSTEM CONSTRUCNON
llation tr Major Repair Repair Alteration l-l Vault and Haul
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-5614
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Garfield County
USA6E WPE
flother Describe
Transient Use n Comm./lndustrial tr Non-Domestic
'Mlwell E Spring E Stream or Creek
PARTIES
Property
Mailing
Email Addressr
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Phone:
Mailing Address
Email Address:
Mailing Addressr
Email Address:
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PROJECTTOCA
Job Addressr
Assessor's Parcel
Buildlng or Service Type
Potable WaterSource
& Type
Co
Block
Disposal(Y/N)--
cDistance to Nearest Community Sewer System:
Was an effort made to connect the Community Sewer System:
D Cistern
D Community Water System Name
-
Garfield County PLtblir; Health Department -- vrrr:rkinr; to prornote health anel prr:vent clisearse
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 dFFartment 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
neceis'ary 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 applie.d for herein. I
furiher understand that any falsifiiation 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 Notlce and Certificatlon above as
well as have provided the required information which is correct and accurate to the best of
my
4/q/as
Pri and Sign Date
Speclal Conditlons:
ooFees Pald:AcnTotal FeesiAut oo'ffi$.od
Balance Due:-o-Buildlng Permlt #W;qns lssue Date:
Garfleld County Publlc Health Department:
Signed Approval Dat€
Garfield County Public Health Departrnent - working to ;rromole health and pr,event disease