HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 62s-5200
Public Health
OWTS PERM IT APPLICATION
RECEIVEN
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201.4 Blake Avenue
Glenwood Springs, CO 81601
{970) 94s-6614
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PROJECT TOCANON ANO DESCRIPNON
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Garfield Çounty Putllic Health Departrnent * working tr: promote health and prevent disease
Applicant acknowledges that the completeness of the aBpl¡cation 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 bv the local health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and coñditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the apþlicant are or will be represented tó be true and
correct to the best of my knowiedge 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 any falsification or rnisrepresentation mayiesult in the d'ehial of the
application.or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby
well
that I have read and understand the Notice and Certificatlon above as
provided the required information which is correct and accurate to the best of
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Owner Print and Sign Date
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Speclal Condhlons:
Permlt Fea:(Ðo @ Tstal Fees:(æa oQ "'"'l2no æ
Eulldlng Permh
bt 7j"r8âra OWTS Permit:.#ffi-ßâg¿t lssue Dater Balance Due:
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Garfield County Publlc Health Department:
Signed Approval Dâte
Garfield County Public Health Departrnent - working to prornote health and prevent disease
09/19/2023
09/19/2023