HomeMy WebLinkAboutApplicationFHB 2 E 2t125
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Public Health
195 w. 14th Street
Rifle, CO 81650
(970) 52s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(e70) s45-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
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El Other Describe
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INVOTVED PARTIES
Property Owner:
Mailing 314 ll RD Glenwood
Emait Address: keenan9492@omail.com
970 r3098164
co 81601
( 970 ) 5892364
Mailing Address
Email Address:aimeolivasl T Lcom
970 2417076
Mailing Address;2516 E Foresi ht Cir #1 Grand Junction CO 81505
Email Address:dro@westwaterco.com
PROJECT IOCATION AND DESCRIPNON
Garfield Coun$
Job Address:
Assessorrs Parcel 239501400064
Building or Service #Bedrooms: 3
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
k
Disposal(Y/Nl N
& Type
Potabte Water Source , E Well tr Spring El Stream or Oeek E Ostern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further'nir'nl-Jtbw liiO iOaitTonal tests and rdports as may be rbiuired by the local health de-partment to be
ilffi;;i'f;iirist'iU -tv
itre ippticant oi by the locilhealtti depart'ment for purpo.se of the evaluation of
i'tieipptiiation; inU ttie issuince of the pbrmit is su.bject to stich terms and conditions as deemed
niiJisirvlo iniure compiiance with rulds and regulaiions made,.information andreports submitted
ff&iti1'ild iiif uireO t6 be submitted by the_applicant are or will be rep.resented to be true and
loriect to the beit of my knowledge and belief and are designed to be relied on by the.local
Oe-pa.t*"ni of treatth in'evaluatinE'the same for purposes of issuing the permit apnlie.d for hereln. I
further understand that any falsification or misrepresentation may result in the denial of the
;dii;;tior ;irevociiion of any permit granted bbsed upon said abplication and legal action for perjury
as provided by law.
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.
.j,b/A5
Propefi Owner Print and Sign
tOFFICIAT USE
Special Condltlons:
'ffngo Fees Paid:oooo
a
Permit Fee:(offi
Balance Due:e155ue Date:OWTS Permlt:ffi,qlu(EuildingPemit
BLrnA -Qtro:lr
Garfield County Public Health Department:
Signed Approval Date
GarJield County Public Health Department - working to promote health and prevent disease
04/16/2025