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195 W. 14th Street
Rifle, CO 81650
(e7o) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 8L601
(s7ole4s-66L4
OWTS PERM IT APPLICATION
Gurfield Coun$
WPE OF SYSTEM CONSTRUCTPN
B. New lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUITDING USAGE WPE
F. Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Propefi C o
MailingAddress
EmailAddress:
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CoMailing Address:
EmailAddress:
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EmailAddress:,(a'
PROJECT TOCATION AND DESCRIPTION
Job Address:b3o
Assessol's Parcel Nu
Building or Service fyp", 5 F A fBedrooms: Garbage Disposal(Y/N
Distance to Nearest Community Sewer System:?-nl nn I le <
Was an effort made to connect to the Community Sewer Syst".t NC)
Potable Water Source
& Type
$.wett tr Sprlng E Stream or Crcek E Cistern
E Communlry Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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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 locdl health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and coirditions 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 td be true and
correct to the best of my knowledge and belief and are designed to be rdlied on by the local
department of health in evaluating the same for purposes oi issuing the permit applied for herein. I
further understand that any falsification or misrepresentation mayiesult in the d'ehial of the
application.or revocation of any permit granted based upon said airplication and legal action for perjury
as provided by law.
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.
Tey.ei 6-,1-zaz;
Owner Print and Sign Date
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oFFtctAt usE oNw I
Speclal Condltlons:
'(fffi'.oo Totel Fees:lxtl ,oO
Fees Paid:&IilT
Bulldine Permit
upE-qu(A OWTS Permlt:
ehhqc.lbcl
lssue Date:Due:
Garfleld County Publlc Health Deprrtment:
Slgned Approval Date
Garfield County Public Health Department * working to promote health and prevent disease