HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Public Health
2014 Blake Avenue
Gienwood Springs, CO 81601
{970).945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New Installation ❑ Alteration ❑ Repair
)Z1UILDING USAGE TYPE
Dwelling ❑ Transient Use 0 Comm./industrial I: Non -Domestic
❑ Other Describe
INVOLVED PARTIES j �li� t/
Property Owner: lI li 4 P4CV l C L O i.i �i Phone: MO 1 I q
Mailing Address:I 1(00 gall Card 1 ' S `Ct g ftr7
Email Address: I C.C.EIS-lind[M_QC E' PL�YY"YDi 'C' k`(lr)
Contractor: OLjYnLr j Phone: ( )
Mailing Address:
Email Address:
- LNG' 3�q 5_Z_ -
Engineer: Phone: rU)O )
rti --t--• i - ..--n
Mailing Address: .33 FOtA } WI -I- DRIV RD C�y 1,OP1) D ..E e I I, 2- 3 r
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Email Address:' , .-1 +,..- -- ...... � .. `_ • .. I CPr . c61130 �P COI AI V
PROJECT LOCATION AND DESCRIPTION
Job Address: �� Lac� 17 (funk Si 11
�'
Assessor's Parcel Number: 2lZ1/S lC C(64ub. Lot Block
Building or Service Type:{ xji Gtie), I'Ti'+(, #Bedrooms: C.1Garbage Dispos/N)
Distance to Nearest Community Sewer System: i an F-T 1 Ol.t 1 !!
Was an effort made to connect to the Community Sewer System: IJ. Z 1 f ay-) rope-Ht.-1
Potable Water Source Well ❑ Spring D Stream or Creek ❑ 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 forherein. 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
my knowledge.
rj r Cif 6 r"0":5)
Property Owner Print and Sign
Date
OFF1aAt USE ONLY
Special Conditions:
Permit Fee:
113,00
Total Fees:
1�.3•00
Fees Paid: ��. D�
Bulldin Permit
-(4 '
OWT Permit:
S ' I/$3
Issue Date:
7/b Pla90
Balance Due:joer
Garfield County Public Health
Department: [o
S' n d Approval Da e
a•OOOCc, (DI2I.2 o