HomeMy WebLinkAboutApplicationRECEIVED
195 W, 141h Street
Rifle, CO 81650
GARFIRIMACAIHEY
COMMUNITY DEVELOPMENT
Le. Garfield County
Public Health
RECEIVED
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GARFIELD COUNTY
COMMUNITY DEVELOPMENT
2014 Blake Avenue
Glenwood Springs, CO 81601
{970) 945-6614
OMITS PERMIT APPLICATION
TYPE OF SYSTEI! L CONS'iRUCT1IC N
19] New Installation
Alteration
Repair
BUILDING USAGE TYPE
Q Dwelling
lather Describe
[]Transient Use
LI } Comm./Industrial (] Non -Domestic
—MOWED WED PA TIES
Property Owner: L,i,\\.( a. A.--� Phone: (970 )(374/- Y�f D °t
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Mailing Address:.EJ Zel., /OS— 2— meted0 Aoti_e_ Co U 1 o.13
Email Address:
Contractor: T \ Q Co eyvf ,t r Phone: (770) 3 79— q
Mailing Address;; 1C 1- 2 i C avirojr►it ( X/ b23
Email Address: IQ ti,\ e 1 t. ( G Sort i 5 t pi.,,
Engineer: lccolik Y y, q l ek eer i AD -I- 11 ( C ) g{1
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JJPhone:
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Mailing Address: 1fa4 G 1. ',CR. Ie. eri e.?ddd' Spii►tj - (O F 1 L'/
Email Address: 41 e_ G,kRiAegz 1, r'+..e,Cife-fi it , CO eve
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PROJECT LOC TIMMO DESCAUP ION
Job Address: t ft j ('m.t,s,.4.! Q.p PO
Assessor's Parcel Number:2S
Building or Service Type;
Distance to Nearest Community
Was an effort made to connect
95558152620Sub. Lot Block
tint?[�(.:i vll/ Si l #Bedrooms: �i i P- Garbage Disposal(Y/N)
Sewer System: diet(' ti
wl
to the Community Sewer System:
Potable Water Source
& Type
=Welt f l lspring m Stream or Creek []Cistern
J
IIM Community Water System Name
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.
further unorsta do that any of falsification
t granted based upon said applcationresult in the denial of the
and legal action for perjury
application or revocation of any p
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
Date
Special Conditions:
Pemit Fee:
Building Permit
OWTS Permit:
5_ = (p1 -1
Total Fees:
Issue Date:
Fees Paid:
c7
Balance Due:
Garfield County Public Health Department: i ' l
Date
Signed Approval
Page 5 of3
Updated Dec 2013