HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
C, Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
J
8 New Installation I
•
Alteration
I
❑
Repair
BUILDING USAGE TYPE
• Dwelling ❑ Transient Use
I D Comm./Industrial
I
❑ Non -Domestic
Other Describe For Bathroom in bam
INVOLVED PARTIES
Property Owner: Stirling Ranch Properly Owners Association, Inc.
Mailing Address: 233 Clipper Place Carbondale, CO 81623
Email Address: Gregor - gidek@aol.com
Phone: (970 ) 379-1907
Contractor: TBD Phone: (
Mailing Address:
Email Address:
Engineer: Carla Osiberg
Mailing Address: 33 Four Wheel Drive Road Carbondale, CO 81623
Email Address: sarla.ostberg@gmail.com
Phone: ( 970 1 309-5259
PROJECT LOCATION AND DESCRIPTION
Job Address: 170 Skipper Drive Carbondale, CO 81623
Assessor's Parcel Number: 2391-292-05-029 Sub. Stirling Ranch
Building or Service Type: Barn #Bedrooms: 0 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: No
Lot Block
Potable Water Source
& Type
B Well
❑ Spring
0 Stream or Creek
0 Cistern
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. 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.
Property/Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Visual and tactile evaluation of second profile test pit. See permit for details.
Permit Fee: $ 123.00
Total Fees: J 23. 00
Fees Paid: 23.00
Building Permit N/A
OWTS Permit:
SEPT-07.2O/4O
Issue Date:
8/27/2020
f�
Balance Due:
0.00
Garfield County Public Health
7
��� 8/27/2020
Department: i V
Sign d Approval Date
PD. $123.00, CC, 7/27/2020
l'a;!c +ot3
Updated Dec 2013