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HomeMy WebLinkAboutApplicationRECEIVED GARfIEY Otis O0P G001.11411 195 W. 14th Street Rifle, CO 81650 (970) 625-5200 Garfield County 1 Public Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970) 945-6614 OWTS PERMIT APPLICATION f TYPE OF SYSTEM CONSTRUCTION MI New Installation ❑ Alteration i BUILDING USAGE TYPE t® Dwelling TO Transient Use ❑ Comm./Industrial Ti ❑ Non -Domestic 0 Other Describe j ❑ Repair INVOLVED PARTIES Property Owner; LL4 i e t,`aty� Le c 1L& Phone: ( Rio ) Z7c1-III LQ�1 Mailing Address: -k-)AoAn i esztC1 1.12 w CCXi'1 00 k 4-i Email Address: I1 So. 9 k o e 1Le (Ct C 4,1,10-t.L1. Ors ill Contractor: ' . Wv,r1 Clam Vt Mailing Address: 11-123 .,?A)ce NL•L•' r �F t C (C) SitE'S� Email Address: ViO)c,k.t. tci y, LACkt1m.(Vinn Engineer: \mal e L V.-t YLO3 - Phone: (i \3S ) i $')--5 (-( 48- -- -- Mailing Address: 1,(2). RUC 1if, g VV1C��t cxlt Si O Th Email Address: V ra u<�A. ikv‘163-t V C CU 4'iellyn ee v11,tc 6. f'c W1 Phone: ( °t 1U .} C, PROTECT LOCATION AND DESCRIPTION Job Address: WUV .3Z41 C IZ Z 11p Le f e. 51(r5G Assessor's Parcel Number:2-1t9ps2©2L+it Sub_ at, o.--1Q.y,Deg Lot 40 clock Building or Service Type: 12 ltBedrooms: Garbage Dlsposal(Y/N) Y Distance to Nearest Community Sewer System: rJ k Was an effort made to connect to the Community Sewer System: Potable Water Source i Lol Well { ❑ Spring I ❑ Stream or Creek ❑ Cistern & Type �-- — -- --------- - - ;� — . _- T ® Community Water System Name V\ 4V�Q«r0ct�+ clEicti45 Garfield County Public Health Department - working to promote health and prevent disease 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 and legal action for perjury as provided by law. i hereby acknowledge that l 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. Lo_c ice Property Owner Print and Sign Z 1s I-zo Date °FPO); ti40:001'lI , I Special Conditions: Permit Fee: 114.00 Total Fees: $123.00 Fees Paid: IZ3. OD Building Permit V 4 //{ `{/� iiQ q % Permit: �(�/�, 10 I 1 J Issue Date: //2. ��7 z, Balance Due: s) f V Garfield County Public Health Department: ". ✓ j� y L l� G J / %% f -- G (" �` GI," �. , i'- t''' — f/Z elAai U Signed Approval Date rD. Il3.o0) cc usw