HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New installation ❑ Alteration
BUILDING USAGE TYPE
cY Repair
® Dwelling
❑ Transient Use
❑ Comm./Industrial
Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Pamela Prokop
Mailing Address: 6191 County Rd 233 Silt CO 81652
Email Address: willpam6s@Uno.com
Phone: (979 ) 421-0381
Contractor: Jason Daubs Altitude Septic
Mailing Address: PO Box 1534 Eagle CO 81631
Email Address: altitudeseptic@gnail.con
Phone: ( 970 ) 471-1330
Engineer: Carla Ostberg
Mailing Address: 33 Four Wheel Dr. Rd Carbondale CO 81623
Email Address: carla.ostberg@gmaif.com
Phone: ( 970 ) 471-1330
PROJECT LOCATION AND DESCRIPTION
Job Address: 6191 County Rd 233 SirtCO 81652
Section, 35 Township: 5 Range: 92 SESWSE, ANTLERS ORCHARD TR 62
Assessor's Parcel Number: 212735400053 Sub. Lot Block
Building or Service Type: #Bedrooms: 5 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
0 Well
❑ Spring ❑ Stream or Creek
❑ Cistern
D Communrty 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.
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
my knowledge.
Pa,sre�a 1 &do/ 05/ 1 1 /2020
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$75.00
Total Fees:
Fees Paid:
$75.00
Building Permit
N/A
OWTS Permit:
SEPT-05-20-6270
Issue Date:
05/Z7�c 1p
Balance Due:
$0.00
Garfield County Public Health
7
Department: //� .E `'
f
s` Z�ZC`0
/Gigned Approval
Date
PD. $75.00, check #3113, 5/14/2020
Page 5 of 3
I_ !Waled Dec 2013