HomeMy WebLinkAboutApplicationRECEIVED
HAP 0 4 2Q20
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
5t New Installation
0 Alteration
0 Repair
BUILDING USAGE TYPE
pit Dwelling T❑ Transient Use T❑ Comm./Industrial 0 Non -Domestic
0 Other Describe
_INVOLVED PARTIES fes,, AAy
Property Owner: AA Ptxur E.LI LEA) )10
Phone: ( 721 -oo,
Mailing Address: 2.18 E V , tf") TIE 1o4 Piur3 37C.
Email Address: f !$3I'I:...[g f,E t=PE RLE, CONAA
Contractor: W R. 11/414 LO&u..9 R.WS 1.0141T0314-1T'y►t -VP-- Phone: 07O ) 2,74— %'f l
Mailing Address: 1 00 9 C+6.T1LE %t f- )13(es R1 0014-646o r>kL£, CD $Ifo2S
Email Address: W 9 --No 5 IicOT7IikAl L i COM
Engineer: 51tUzc7 '7ts..twi 51-r Li -t 4 t 3
Phone: (°NO 1 �'oO-1Oo3
Mailing Address: 4 e r Ii14t.C AWL CO iib i
Email Address: M 0i 3 bEPZZVSOPG1A. /NS s<r
PROJECT LOCATION AND DESCRIPTION
Job Address: L[t?R Cnrrt, C -L,L 2 iDfoE__ CAAE2i,tLsbiku. CO it 162_•3
2ai4f-dG I -Dv RA,PoLbk/ r&XL:11 e
Assessor's Parcel Number: I Sub.0 Ce - Pu 17 Lot ` Block _
Building or Service Type:Si LL '-L. #Bedrooms: 3 Garbage Disposal(Y/N)_q___
Distance to Nearest Community Sewer System: NI rk
Was an effort made to connect to the Community Sewer System: NO
Potable Water Source
& Type
Well ❑ Spring ❑ Stream or Creek I D Cistern
Ig Community Water System Name J G►► -#•t CcJ L rts7_
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 niay 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.
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 1 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
niy knowledge.
R06 - %lam - Milo( t~ 1
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
123.00
Total Fees:
Fees Paid:
i23. oo
Building Permit
01/ -19145
OWTS Permit:
scpr- (Di i-�
issue Date:
3j� j
Balance Due:
County Public Health
Garfield Co y
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Department: ,/ IQ - 1 , / r A i.2 t-. 05/ (-7/,- ,,,
P e.�i
Signed Approval Date
?D.$ %23. Po) ;033) al 7.O20