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195 w. L4th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-66L4
OWTS PERM IT APPLICATION
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WPE OF SYSTEM CONSTRUCTION
E New lnstallation ! Major Repair ! Minor Repair n Alteration ! Vault and Haul
BUILDING USAGE TYPE
E Dwelling E Transient Use n Comm./lndustrial tr Non-Domestic
I Other Describe
INVOLVED PARTIES
Property one:
MailingAd
Email Address:
Phone: ( )
Mailing Address
Email Address:fat\O^ \.¿r a n n' ,. Q-l-Lr'a. \^^.t ft Lf \¡(Ñt g-' v ,\'r
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Enginee e:'11Otrq:
Mailing Address
Email Address:
PROJECT TOCATION AND DESCRIPTION*Èb Àii*;;'f.ti i e ;; r. - R-l--- r.t. 'Â ù;
Assessor's Parcel Number:drrq oitl o ¡o Block
Building or Service edroomsr 5 Garbage oisposal(Y@
Distance to Nearest Community Sewer Syste m: ñ.,k [ì'ncrûcrct\\.i Ëec,<..l,h\<-
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
þwett ! Spring n Stream or Creek E cistern
I Community Water System Name
Gerä*ltl ü*:r:nty Èr*h!i* ù-{**lth S*prirt**nt * w*rkin¡¡ t* ¡::r*n':*t* h*slth *** pwrs*lrt dis**se
CERTIFICATION
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.
Print and Sign Date
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 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 terms 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 for purposes of issuing the permit applied for herein. I
further understand that anyfalsification or misrepresentation may result in the denialof the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
OFFICIAL USE ONLY
Special Conditions:
Permit Fee(,-oô oo Total Fees:(Ø OO Fees Paid:êo(ç@
Building Permit
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OWTS Permit:
?#T-R\RO
lssue Date:Balance Due:
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Garfield County Public Health Department
Signed Approval Date
ü*$islcJ tì*unty Ëublic $-ìe*lth l)*p*rtmnnt ..- wt¡rltin¡¡ tn prom*t* h*ç:ith *ncl ¡:r*vent riise¡¡**
07/26/2023
07/27/2023