HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation ; IA Alteration I ❑ Repair
BUILDING USAGE TYPE
® Dwelling I El Transient Use 0 Comm./Industrial 0 Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Franklin Mountain Glenwood Springs II LL Phone: ( 970 ) 274-3223
Mailing Address:
Email Address: mikegoscha@gmail.com
Contractor: Clayton Homes
Phone: (970 ) 245-9039
MailingAddress: 671 23 Road Grand Junction, CO 81505
Email Address: david,mahovsky@claytonhomes.com
Engineer: Ken Brotsky Phone: ( 970 j 216-8861
Mailing Address:
Email Address: kbrotsky@yahoo.com
PROJECT LOCATION AND DESCRIPTION
Job Address: 1877 Canyon Creek Rd Glenwood Springs, CO 81601
Assessor's Parcel Number: 212323200064 Sub.
Lot Block
Building or Service Type: Single Family Residence t$Bedrooms: 3 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System: Several mites
Was an effort made to connect to the Community Sewer System: No
Potable Water Source 1 ® well ❑ spring i 0 Stream or Creek
& Type ❑ Community Water System Name
0 Cistern
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 artinn for perjury
as provided bylaw.
1 hereby acknowledge that I have read end under tand the Notice and Certification above as well as
have provided the required information jiTsmect sad accurate to the best of my knowledge.
Sandra N Mendez
S a1n.kY'a N itt.at.6 /18/ 2 0 20
Property Owner Print and Sign
i�44 IAISH...
Date
OFFICIAL USE ONLY
Special Conditions: t 11 44 p /
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Permit Fee: sir 00
Total Fees: f QO
iN•
Fees Paid: 4. oct
Buildkn Permit
F— (�
OWTS Permit:
�
5 ' V 3/V A
Issue Date:
Issue
9/22/2020
Balance Due:
Garfield County Public stealth
,1 /
Department: 1 a0 ao
Signed Approval Datc
flo.ems LV r 255011 J
Page5of3
Updated Dec 2013