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
71 New Installation
BUILDING USAGE TYPE
G1 Dwelling I ❑ Transient Use 0 Comm./Industrial I 0 Non -Domestic
0 Other Describe
❑ Alteration
Repair
INVOLVED PARTIES AlProperty Owner; s� S ,_ t,,. ! J- LL Phone: ( 1 i J qe3 y2
6, j)1 !J
Mailing Address: T5 / Ivy G. if 2TQ1
Email Address: J 3 0/iu'e-456fJ06 //no.' / r•-62/11
Contractor: Phone:( )
Mailing Address:
Email Address:
Engineer: hl / 197 E S
Phone:(
Mailing Address: ISO 2O C ' )ST
PROJECT LOCATION AND DESC IPTION
Job Address: L; *57 iA
Assessor's Parcel Number:
Building or Service Type: I'Vi
Distance to Nearest Community Sewer System:
Email Address:
114
Sub. tijia_SIP--1 1,.t-e) Lot Block
#Bedrooms: 3 Garbage Disposal(Y/Nr
hi- N!
Was an effort made to connect to the Community Sewer System:
Potable Water Source TVWeil ❑ Spring 0 Stream or Creek i ❑ 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 have prov' d the required information which is correct and accurate to the best of
my knowled
Prope ner Print and Sign
OFFICIAL USE ONLY
Special Conditions:
Date
,202
Permit Fee: Total Fees: 11
4
(WITS Permit TS Permit: Issue Date:
gam-V2lle SEPT- I,11l .." /zwz�
Fees Paid: 23
Balance Due:
Garfield County Public Health Department:
P_ �_ .5/2 ' t•
Signed Approval
Date
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