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195 W, X4th Street
Rifle, CO 81650
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Pablìc Heø.lth
OWTS PERMI T APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 8L601
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üurfield Counfit
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Wâs ân êffort made to connect to ttre Community Sewer System:
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Assessor's Parcel
Building or Servlce
System:Dlstâncß to N€arest ComrnunltY
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E Communlty Water Sy$em Nam€ . --- . . .
Garfleld Ëuunty Publlc Hsaltli DepaÉment.* worklng to promolê heâlth and plovent dlseâse
Aoplicant acknowledges that the completeness of the application is conditio¡al .upon such further
;"#¡i"ü;n;i;;ãñionail;;iïáñ¿ råóorts as rnay be r'eiuired by the local health department to be
ffiäË:äi;;ñ.i:,äËtä" ãóï1rcãri i,'r. uv ttrè iocál t ealth aeparfment for.purpo.se of the evalu_a_tion of
iü;;päl;;t'ä#;ã;tí* ¡;;JåtiC" ıf it'" pérmit is subject to srich terms and conditions as deemed
necessarv to insure.o*ptir*ã*¡ttr-iulås and regulaiions made,-informat¡on and.reports submítted
ü;;;;i;it""ïiãılirããlı ú" zuumitieã by the.apþlicant are or will be represented to be true and
;;i*¿t-6ìh" Ui-st oi mv ¡n-o*lãáãà and belief åÅ¿ are designed to be relied on by the.local
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¡reáfitr in'evaiuat¡nätne same for purposes oi issuing the. permit appl¡e.d for herein. I
f;ñú; ñff;tãnäitråï ànv i¡sitiËai¡on or misreþresentation mayiesult in the denial of the
;ïòi;i¿ti,ñ;¡. t""o.äi¡on öi åãv pãiñi¡t cianted 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 Certlflcatlon above as
well as have provlded the required informatlon whlch is coffect and accurate to the best of
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Special Conditlons;
Ti'#.*Tótal Fees:
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Balance Due:
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Permit
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Garfleld County Publlc Heâlth oepartment:
Signed Approval Date
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