HomeMy WebLinkAboutApplication - PENDINGCERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such
urther 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
�erms 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 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
or purposes of issuing the permit applied for herein. I further understand that any falsification
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 know edge.
:.LaA�l:lerst, Public Works Director 3-18-2026
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: Total Fees: Fees Paid:
Building Permit OWTS Permit: Issue Date: Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department -working to promote health and prevent disease
$600.00 $600.00 $600.00
N/A SEPT-9738 $0.00
Paid 03/19/2026 Visa $600.00