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195 W. 14th Street
Rifle, CO 81650
(e70) 62s-5200
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(e70) e4s-6614
OWTS PERMIT APPLICATION
Gurfield County
TYPE OF SYSTEM CONSTRUCNON
Ef, New lnstallation El Mtajor Repair E Minor Repair E Alteration E Vault and Haul
BUITDING USAGETYPE
J} Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVEDPAfiNES
rPropefi
Email Address:
Mailing
.f"Mailing Address:
EmailAddress:
Mailing Address:
Email Address:
PROJECT TOCANON AND DEgCilPIloN I
Was an effort made to connect to the Community Sewer System, -
.-
Disposar(Y/N\Y-
Distance to Nearest Community Scwer System:
Job Address:
Assessor's Parcel Number
Building or Service
E Sprlng n streamorCreek
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E Cistem
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Il WellPotable litater Source
&Type A c.ommunity wat€r syst em name f/* il n/,em.e r&/w/E <,
Garfielcl County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application isconditional .upon such further
mandatory and additlonal tests and reports as may. be required by the local health department to.be
made and furnished bv the applicant oi by the locil health department for purpose of the evaluation of
the application; and tlie issuince of the permit is subject to such terms and conditions as deemed
neceis'ary to iniure compliance with rul6s and regulations made, information and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be rep.resented to be true and
correct to the beit of my knowledge and belief ind are designed to be relied on by the local
department of health in'evaluating the same for purposes of issuing the.permit apRlied for herein. I
further 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 Notice and Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
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Property Owner Print and Sign Date
a
OFFIOAL USE
Speclal Conditions:
Fees Paid:
|r*^c,o,cnTotal F€es:oo(ffiPermit Fee:[61 .@
Balance Due:lssue Date:Building Permh
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OWTS Perrnlt:Swtqlq,-?
Garfield County Public Health Department:
SignedApproval DatG
Garfield County Public Health Department - working to promote health and prevent disease
4/16/2025