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195 W. 14th Street
Rifle, CO 81650
(970) 62s-s2oo
Public Health
OWTS PE RMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(e70) 945-5614
Garfield County
1 WPE OF SYSTEM CONSTRUCNON
New lnstallation
BUILDING USAGETTPE.tiffi*"t
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tr Major lr fl Minor rr E Alteration fl Vault and Haul
fl Transient Use n Comm./lndustrial D Non-Domestic
E Other Describe
INVOLVED PARTIES
Property
Mailing
EmailAddress:
Mailing Address:
EmailAddress:I
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Mailing Address lzq
EmailAddress:
PROJECT TOCATIOTTI AND DESCRIPTION
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c;,IJob Address:
Garbage Disposal{Y/N}3__
, Was an effort made to connect to the Community Sewer System: P l*
potableWaterSource : fl Well I Spring fl Stream or Creek I Cistern
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&Type Community Water System Name
Garfield County Public Health Department -working to prornote health and prevent disease
Aoolicant acknowledses that the completeness of the application is conditional upon such further
;";ffi;il;;d ;;eitT*af Gsti and reports as may be rbiuired by the local health de-partment to.be
made and?urnished by the applicant or by the local health department for purpose of the evaluation ot
iiii rpplii"ti;;; ;n; itie issuince of the. pbrmit is su.bject to such terms and conditions as deemed
n*iJiliw to lniure comptiince with rules and regulaiions made,.ll,formation !ld,,r^"!otts submitted
ft"i!*itft'.iiO requirea t5 Ue iuUmitted by the -apllicant are or will be representqd 19 be true and
;;r# io ih; UdLi oi mv tnowtedee and belief ind are designed to be relied on by the local
lEor-rtitii"i or nuitit' in'evaiuatinfi the same for purposes of issuing the. permit apRlied for herein. I
i;i[; ;d;iitinO itrai any falsifiiation or misrepresentation may result in the.denial of the
lppiiiation or reuocaiion of any permit granted b'ased upon said aiplication 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 corect and accurate to the best of
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Propefi Owner Print and Date
$peclal Condhlons:
Fees Paid:ooTotal Fees:e)oPermit Fee:po
Balance Due:lssue Date:OWTS Permit:
Signed Approval
Garffeld County Publlc Health DePartment:
Date
5/19/2025