HomeMy WebLinkAboutApplicationRECEIVED
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GARFIELD COUNTY
COMMUNITY [DEVELOPMENT
195 W. 14th Street
Rifle,.to 816501_
970 625=5200
Gar el d County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
1970) 945=6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
+5
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n Neu/ Installation
Ld Alteration
iiia Repair
..BUILDINGIJSAGE TYPE
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Phgnelf. it? .1-
Dwelling Transient Use
Comm./Industrial
i Non -Domestic
ther-Describe
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Engineer �C 4.', 3dck Phone (01 70 1 S (" rib
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EmailAddress: STt)C(O,Q DIAet 0,5tvack .f.O1\\
PROJECT LOCATION AM?
INVOLVED PARTIESW
Property Owner m Volk 4 �� a(ktlt f .)P.hon8(Sr"(5c
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MailingAddress,�-(-�_T,
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Email Address ithi roger
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Phgnelf. it? .1-
Colitrac"tor ... ,' tE9eIS
Mailing Address: 5_15_30(4) s.k_�TQ 4% o i c st.
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EmailAddress� Cn.f,font,oiLI"C•g-t(takMAA.rOM
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Engineer �C 4.', 3dck Phone (01 70 1 S (" rib
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MailingAddress 9,Itc0 -cct .. _ (4 ?la i (0 %k G6 6'
EmailAddress: STt)C(O,Q DIAet 0,5tvack .f.O1\\
PROJECT LOCATION AM?
DE$CPTION
+ dR SIPS 1ypv.S V'
Job Address moi
Assessor's Parcel Number:aq
Buildingor Service Type
Community
Wasan ellen matte to connect
calico -Sub. t\Qy 1 NT) ...el...el=d
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Lot -.- Block .. -
t rr0.- tel4n y ) 0tvAp- tlBedrooms: Garbage Disposal(WN) (3
Sewer System: I. Q
21,0
to.the Community sewer
______,__Distance
__,,_.: _:,._,_ _
System: Q
Potable Water Source
- all - =Spring
IJStream or Creek
■ Cistern
&Type .. __
(]Communitywetersystem
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 local 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 an -d legal action for.perjury
as provided bylaw.- - -
hereby acknowledge that I have read and understand the Notice and Certification above as
well as e provided the required information which is correct and accurate to the best of
my kn edge.
Property Owner Print an
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OFFICIAL USE ONLY
Special Conditions: 1
y. C,jc- c gal r(3, 0W)aO
51516,nVo hu (_on5`- vc�c) as 51,0, -JA sn 00,-\s 6o
Permit Fee:
Total Fees:.
Fees Paid: 3.5
Building Permit
F-40101
OWTS Permit:
--
blue Date:
3 Li / .oav
Balance Due:
Ep` '--&Ion
Garfield County Public Health
Department: C0L- 3/H)
pap
Signed pproval Date
M.46 001 4--1610) l )2 t7,o7o