HomeMy WebLinkAboutApplicationRECEIVED
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GARFIELD COUNTY
COMMUNITY DEVELOPMENT
195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
0 New Installation El Alteration
BUILDING USAGE TYPE
® Dwelling 1 ❑ Transient Use
❑ Other Describe
❑ Repair
❑ Comm./Industrial 0 Non -Domestic
INVOLVED PARTIES
Property Owner: Shane & Amanda David
Mailing Address: 2241 Dolores Way -Carbondale, CO 81623
Email Address: s.david@davidelectric,L s
Phone: ( 970 ) 618-9845
Contractor: Shane 6 Amanda David
Mailing Address: 2241 Dolores Way -Carbondale, CO 81623
Email Address: s.david@davidelectric,us
Engineer: All Service Septic -Carla Ostberg
Mailing Address: 33 Four Wheet Drive Rd -Carbondale, CO 81623
Email Address: Carla.ostberg@gmail.com
PROJECT LOCATION AND DESCRIPTION
Job Address: 422 Cty Rd 162-Carbondale, CO 81623
Phone: (97° ) 618-9845
Phone: (970 ) 309-6259
Assessors Parcel Number: 2391-292-05-021 sub. Stirling Ranch Lot 21 Block
Building or Service Type: Residertal #Bedrooms: 5 Garbage Disposal(Y/N) Yes
Distance to Nearest Community Sewer System: Greater than 100' from proposed soil treatment site
Was an effort made to connect to the Community Sewer System: NIA
Potable Water Source ® Well 0 Spring ❑Stream or Creek 0 Cistern
& Type 0 Community Water System Name
Garfield County Public Health Department — working to promote health and prevent disease
CERTIFICATION
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 lucal health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and conditions 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 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 same for purposes of issuing the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the denial 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 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.
Property Owner Print and Sign
02/20/2020
Date
OFFICIAL USE ONLY
5peclal Conditions: rdi/ecc per p(a it.f gv iv ot I t V( C51/Z7//Zdzc'
Permit Fee:
Building Permit OWTS Permit:
B E-'13o sE `- 0131
Garfield County Public Health Department:
Total Fees:
Issue Date:
Signed Approval
FM p4 00j J# t (hfLF-1 . j►�t IZa7.o
3/23/2020
Fees Paid;
00
Balance Due:
$0.00
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Date