HomeMy WebLinkAboutShambahla Therapy LLC Zoning Verification 2018O#zi erof Behavioral}realth
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SUD —Substance Use Disorder State Licensure Program
ZONING DEPARTMENT - Zoning Use Confirmation - Sign off for Local Authorities
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF THE APPLICATION: 0 Initial Application
• Renewal Application
O Modification — Change in location
Type of Substance Use Disorder
services being provided:
O Residential / Transitional IN Outpatient
❑ Day Treatment
SECTION B: TO BE COMPLETED BY THE APPLICANT — PHYSICAL SITE LOCATION
Current Name of Agency: Shambahla Therapy, LLC, DBA, Alpine Springs Counseling P.C. (ASC)
Address: 19 Vail Rd
City: Vail
zip: 81657County: Eagle
Name of Contact Person for any questions: Kelsey: kelsey@alpinespringscounseling.com
Phone: (970) 485-4474 Fax: (888) 215-8940
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
(this section must be filled out by the proper authority to be considered a valid document)
Zoning Department having jurisdiction: 1 WVI. �� I/ t 1
The above named facility meets the requirements of the local authority having jurisdiction for the occupancy
based on work outlined above. (If "no", please explain on a separate attachment) YES 0 NO
Signature: Date: P7 7r' ^ 3 (^ S
Printed Name:
GIA N b�
Title: 7t ci frt- 5 AA't
Address: �� s• 'v 2 d' • City: Vo.,; Zip: i 5
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