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GARF I Ë ¡-Ll Ç tj i", l-J'f Y
COM MUNITY I'J ËVE LOFMËIiT
195 w. L4th Street
Rifle, CO 81650
(970) 62s-s200
Publíc Heølth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
Gurfield County
t Other Describe
WPE OF SYSTEM CONSTRUCTION
x'New lnstallation trM fl Alteration n Vault and Haul
BUITDING USAGE TYPE
Dwelli Ü Transient Use Comm,/lndustrial Non-Domestíc
INVOLVED PARTIES
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Property Owner:
Mailing Address
Email Address:
e:
tMailing Address:
EmailAddress:
Was an effort made to connect to the Community Sewer System:
PROJECT TOCATION AND DESCRIPTION
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Ncr
Ga rbage Disposal(Y/rooms
EmailAddress:
Distance to Nearest Community Syste
Job Address:
Mailing Address:
Assessor/s Parcel N
Building or Service
p wett E Spring E Stream or Creel<I cistern
I Community Water System Name
Potable Water Source
& Type
Garfield County Public Health Department - working to promote health and prevent disease
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CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
manctatory and additional tests and re¡rorts as may be required by the local health department to he
made and'furnished by the applicant or by the local health department for purpose of the evaluation of
the application; and tlie issuance of the permit is subjeet to suclr terms ancl conditir¡ns as deemed
neceisary to insure compliance with rules and regulations made, information and reports submitted
herewith'and required tó be submitted by the apþlicant äre 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 sarne for purposes of issuing the permit applied for herein, I
fuither understand that any falsifiiation or misrepresentation may result in the elenial 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 t have read and understand the Notice and Certifícation 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
OFFICIAL UsE ONLY ?a.ld.?- b- A.4
Special Conditions
Ferr¡it Fee¡Uoo oO Total Fees:b(Y.æ Feeç Paid os@
Building Perrnit
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OWTS Permit:
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lssue Date:Balance Þue:
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Garfield County Public Health Departlnent:
Signed Approval Date
Gadield Counlv Public Health Depadment - workinq to promote health and Frevent cJisease
7/31/2023
'lrr \¡vlì()tìì it ctÏtct nìs,
A¡lott Dirler has [reen ret¡ined by I'1. Arvicl .ulci.|.¡nel Johnsolr as Owner Re¡rrcsent,ttivc fol llre ¡tfiillr¡rr
to the existing residence of a honte locatecl ilr Gadielcl County et 47l County Ro¡d I I /, (i;rrbondale ( o
wlrich property is owned try H Arvid and Janet.lohnson. ln his capacity as CIwner's Representatlve, Â.vorr
Deler is representìng the interest of the Ownem of 471 County Road I 12 when clealing with lor:.r1, st¿te,
and federal governmental âgencies, as well as st¡bcontractors, rnatel'ial sup¡rlies, and colrst¡ltants
involvecl with the addition to 471 County Roacl 1L2.
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H. Arvid nson