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
8 New Installation
❑
Alteration
0
Repair
BUILDING USAGE TYPE
IR Dwelling ! 0 Transient Use
❑ Comm./Industrial
0 Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner; us DEPTOr ENERGY Phone: (
Mailing Address: woo Independence Ave SW Washington, DC 20585
Email Address:
Contractor: TEPRocky Mountain LLC Phone: ( 07a
) 285-9377
Mailing Address: PO Box 370. Parachute. Ca a1s35
Email Address: KMcInlosh@lerraap.com 10Hotard@lerraep.com
Engineer: Fox Engineering Solulians.Inc. Phone: (970
) 250-5505
Mailing Address: 670 Canyon Creek Drive, Grand Jundion, CO 81507
Email Address: toloredofoxQhrennart.net _-_-_ __,_._.._._—_.__ _.._..
PROJECT LOCATION AND DESCRIPTION
Job Address: RWF 12-3 Pad
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
217508200953 Sub.
Lot Block
small Temporary Employee Housing #Bedrooms: 7
Garbage Disposal(Y/N) N
Sewer System; NA
to the Community Sewer System: NA
Potable Water Source
& Type
❑ well 0 Spring 1 0 Stream or Creek
❑ Cistern
111 Community Water5ystem Name cayurwnz
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 th 'red information which is correct and accurate to the best of
my knowledge.
roperty duGner Print and Sign
e &VA /449 .14 "61,
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OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$75.00
Total Fees:
$75.00
Fees Paid: $75.00
Building Permit
OWTS Permit:
SEPT-09-20-6514
Issue Date:
p`f/>'C>/i7 -''
Balance Due: $0.00
Garfield County Public Health
i
Department o r• rl , C71/:0/
Signed Approval Date
PD. $75.00, CC, 9/28/2020