HomeMy WebLinkAboutApplicationRECEIVED
GARFIELD COUN
COMMUNITY DEVELoa
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
03 New Installation 0 Alteration 0 Repair
BUILDING USAGE TYPE
Pr Dwelling 0 Transient Use ; 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES +-�
Property Owner:CL 6 Wt. %"
(5t Phone: ( �,, }6L 3 -a �f
Mailing Address: ' � , Peg 100 i- �CIL44 C orb.1-3
Email Address: fit. 4 ( -f50191.44 >
Contractor: J .t& 5 gxCsf-V --- Phone: ( c00 ) 9 63 —AZ?
Mailing Address: rPOo (+ `�c4 -'�- a 8
Email Address:
l :t A Jc ��I6lr :eK£ i(a"ti"COWL
Engineer,W0fit ^ ❑� Phone: t q 70 } .. -5.2547
Mailing Address: 33 f Off- e -t-) 'a ►Q1' v- k 0)a/Z
4.3
Email Address: 6A/40.. OS€ - 1 . Cii A"
PROJECT LOCATION AND DESCRIPTION
Job Address: 00,--A5 Gk. too Cer-kb31-41-6'.II 8.0'°'23
Assessor's Parcel Number:1313 "j�+Y` }4Ca-c.o.,' AL
ub.
E,xt lot 3 Block
Building or Service Type: r side+ 1 #Bedrooms: Garbage Disposal{YEN]
Distance to Nearest Community Sewer System: 1/2 �•La,
Was an effort made to connect to the Community Sewer System: / k)
Potable Water Source Well ❑Spring 0 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 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, 1
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 �(4Jghvaeveeperovided the required information which is correct and accurate to the best of
l 5 nL*LL riew
Property Owner Print and Sign
OFFICIAL USE ONLY
Spedal Conditions:
Permit Fee:
/use
Total Fees:
2-1 '14 ?at'
Date
Ilding Permit OWTS Permit: Issue Date:
tr -(II0 - L1 G ayitna o
Garfield County Public Health Department:
Fees Paid: 123 0 y
Balance Due: A
(52
P E, 03/0a497
Signed Approval Date
fY\ 12-3 oO) r' jif' I to ? , 2,17,0/040