HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
8 New Installation
0 Alteration
BUILDING USAGE TYPE
® Dwelling I 0 Transient Use
❑ Other Describe
❑ Repair
I 0 Comm./Industrial I 0 Non -(Domestic
INVOLVED PARTIES
Property Owner: James P. & Kelly Cleaver Phone: ( 970 ) 309-9969
Mailing Address: 3724 CR 115, Glenwood Springs, CO 81601
Email Address: Kelly Cleaver <Kelly,cleaverl@gmail.com>
Contractor: Great Lakes Construction, Chris Lake Phone: ( 970 ) 379-0161
Mailing Address: PO Box ., New Castle, CO 81647
Email Address: glcchris <glcchns@yahoo.com>
Engineer: Sepia Engineering, Paul Rutledge andYancy Nichol Phone: ( 970 } 704-0311
MailingAddress: 502 Main Street, SuileA3, Carbondale. CO 81623
Email Address: prutledge@sopriseng.com
PROJECT LOCATION AND DESCRIPTION
Job Address: 3724 County Rd 115, Glenwood Springs Co 81601
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
218729200077 Sub. Lot Block
RESIDENCE ttBedrooms: 5 Garbage Disposal(Y/N} N
Sewer
to the
System: >3miie
Community Sewer System: NIA
Potable Water Source
& Type
a Well
❑ Spring 0 Stream or Creek
0 Cistern
❑ 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. l
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.
Kelly Cleaver
Property Owner Print and Sign
9/08/20
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123_00
Fees Pat
$123.00
Building Permit
N/A
OWTS Permit:
SEPT-10-20-6528
Issue Date:
(Ulij/ O .7
Balance Due:
$0.00
Garfield County Public Health
Department: g 11 G i< - iO4 7
,-%j4'`--'7L
J
Signed Approval Date
PD. $123.00, CC, 10/8/2020
Page 5 of 3
l On led Dee 2013