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HomeMy WebLinkAboutApplication195 W. 14th Street Rifle, CO 81650 (970)625-5200 e. Garfield County Public Health Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970) 945-6614 OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION ® New Installation 1 ❑ Alteration 1 0 Repair BUILDING USAGE TYPE ® Dwelling 1 0 Transient Use 1 0 Comm./Industrial I 0 Non -Domestic O Other Describe INVOLVED PARTIES Property Owner: CMH Homes Inc Mailing Address: 671 23 Road Grand Junction, CO 81505 Email Address: stacI.douglas@claytonhomes.cam Phone: ( 970 ) 245-9039 Contractor: Clayton Homes Mailing Address: 671 23 Road Grand Junction, CO 81505 Email Address: stacl.douglas®claytonhomes.com 1 Phone: { 970 j 245-9039 Engineer: CIVCO Engineering 1 Vance King Mailing Address: PO Box 1758 Vernal. UT 84078 Email Address: vanceking©civcoenglneering.com Phone: (435-78q-5448 PROJECT LOCATION AND DESCRIPTION lob Address: TBD County Road 301 Parachute, CO 81635 Assessor's Parcel Number:2405-0640-0085 sub. Bngman Corner Lot 1 Block Building or service Type: Single Family Residence #Bedrooms: 3 Garbage Dlsposal(Y/N) N Distance to Nearest Community SewerSystem: Several miles Was an effort made to connect to the Community Sewer System: No Potable Water Source El Well J 0 spry © stream or creek j © Cistern & Type 0 Community Water System Name 11 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 aw ation of any permit granted based upon said application and legal action for perjury ar 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: Permit Fee: 4i23.i� Total Fees; pv Fees Paid: `T ,2r 3 Building Permit 3Lh1V- 660I OWTS Permit: Sept'1v502- _! Issue Date: Balance Due: r er Garfield County Public Health A Department: ‘k; d ' Il iu 6��c Signed Approval Date PD.x I7_3• op) t--5215114, q18�2D2 Page 5 of 3 Updated Dec 20 t3