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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 / r`C-e5Sia2Ui 5y5ewL Giccesse�Ptt;-' to h Co�,��0c.tec'( C� rA061-1A5 gu4'(5 CvniPCHcn cr rz°Sr c, 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