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Home My WebLink AboutApplication195 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 BUILDING USAGE TYPE ❑ Alteration I ❑ Repair Dwelling I ❑ Transient Use ❑ Other Describe ❑ Comm./Industrial ❑ Non -Domestic INVOLVED PARTIES r�r _ (— Property Ownerare 0. (Z _ L}1(�te 1 t_CCt,((UMPhone: (C ! b) 2im Mailing Address: PO BiN. 19 t €(Inwood SpriNs, CO 8t(o2 Email Address: meccaWry-‘b of 6+ifet' COYV n Contractor: 043" 11j �x drs V 1 R Phone: (C170 ) ; QC[ L- '41t Mailing Address: sOSACL l er; ctc excunch �iC.� hrlGl l • Cory-1 Email Address: t2(61 CL 1\ &LaWOOd S,�nnCs, C� BRQo I Engineer: �CUm6i C�YLd }��5QC�1 �5 Phone: (crto f qq5-9-q Mailing Address: S020 CQunty� Roo`a Gbvn,wOod SORT) ) CO gI Email Address: 60)011.. t-UYADV(US O • COYYZ PROJECT LOCATION AND DESCRIPTION Job Address: P (313 J L C 2_ G'-kii w ood Spy-) 1 CO 3VA: i) Assessor's Parcel Number:218314-30i ooZSub.ig1 chards on Lot 2- Block Building or Service Type: domes- -1 C #Bedrooms: 3 Garbage Disposal(Y/N) N Distance to Nearest Community SewerSystem: ml teS Was an effort made to connect to the Community Sewer System: Potable Water Source & Type Weil 0 Spring 1 ❑ Stream or Creek I 0 Cistern 0 Community Water System Name Garfield County Public Health Department -working to promote health and prevent disease 201 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 hearth in evaluating the same for purposes of issuing the permit applied for herein. I 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. K-1,44 cv use tz_e�Cu In 1 t t CO.) Q ouv e 01/4-Q4.NO 2026 Property Owner Print and Sign /"2o2 Date OFFICIAL USE ONLY Special Conditions: Permit Fee: $123.00 Total Fees: $123.00 Fees Paid: $123.00 Building Permit BLRE-06-20-6339 OWTS Permit: SEPT-06-20-6340 issue Date: 7/20/2020 Balance Due: $0.00 Garfield County Public Health Department: / Q 7/�o/aoao Signe Approval Date PD. $123.00, CC, 6/22/2020 Page 5 of3 Updated Dec 2013