HomeMy WebLinkAboutApplication195 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
Property Owner: Gary and Amanda Littell Phone: (970 ) 948-7901
Mailing Address: 969 County Road 113, Carbondale CO 81623
lA New Installation
■ Alteration 1 ■
Repair
BUILDING USAGE TYPE
Email Address:
• Dwelling • Transient Use
■ Comm./Industrial
❑ Non -Domestic
D Other Describe
PROJECT LOCATION AND DESCRIPTION
Job Address: 969 County Road 113, Carbondale CO 81623
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
239317200093 Sub. Lot Block
Single Family Home #Bedrooms: 6 Garbage Disposal(Y/N)Y
INVOLVED PARTIES
Property Owner: Gary and Amanda Littell Phone: (970 ) 948-7901
Mailing Address: 969 County Road 113, Carbondale CO 81623
Email Address: gary@littelielectric.com
Contractor: TBD Phone: ( )
Mailing Address:
Email Address:
Engineer: CBO Septic Consulting, Inc Phone: ( 970 I 309-5259
Mailing Address: 33 Four Wheel Drive Road, Carbondale CO 81623
Email Address: carla.ostberg@gmail.com
PROJECT LOCATION AND DESCRIPTION
Job Address: 969 County Road 113, Carbondale CO 81623
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
239317200093 Sub. Lot Block
Single Family Home #Bedrooms: 6 Garbage Disposal(Y/N)Y
Sewer
to the
System: Unsure. Miles away
Community Sewer
System: None available
Potable Water Source
& Type
VI Well
0 Spring
❑ Stream or Creek 0 Cistern
❑ 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 have provided the required information which is correct and accurate to the best of
mykno; -dge.
Prope y O ner Print and Sign
4/15/2020
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
OWTS Permit:
SEPT -04-20-6221-a
Issue Date:
GLfl��r�u:
Balance Due:
$0.00
Garfield County Public Health
Department: _ �
�
Signed Approval Date
P0. $123.00, CC, 4/15/2020
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