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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 1 0 Alteration 0 Repair B ILDING USAGE TYPE Dwelling 0 Transient Use 1 0 Comm/Industrial 0 Other Describe I❑ Non -Domestic INVOLVED PARTIES .,. Property Owner:: _ �WI ) 14,nB- , �rI{ Phone: (q")0 ) 6i4.3'#1 Mailing Address: Email Address: 214 cR z z'- R1fk, Go f16So I" EAVerili't Com Contractor: ios e yvnye Mailing Address: Email Address: Phone: (q10 ) 945 -3pie7 Engineer Cc,r 1s Qin{ heti Mailing Address: 33 &W k4e1 De;vy Read CciIwn4r4 co 81623 Phone: (9'f0 )30q- 5159 Email Address: C4.-14, us -H&J -90901n( 1.4s,M PROJECT LOCATION AND DESCRIPTION Job Address: Z, "LCR 7.z'- Mile, Co $1650 Assessor's Parcel Number: 21491 -°Pr - tb. Lot Block Building or Service Type: Resat. i i A 1 #Bedrooms: K Garbage Disposal(Y/N) N Distance to Nearest Community Sewer System: 10 f Ali les' Was an effort made to connect to the Community Sewer System: A4 Pv+ 0V See .4 wi ec Potable Water Source cyt Well 0 Spring ❑ Stream or creek 0 Cistern & Type ❑ 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. 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 the required information which is correct and accurate to the best of my knowledge. im: Property Owner Print and Sign Io/?6/ moo Date OFFICIAL USE ONLY Special Conditions: Permit Fee: $123.00 Total Fees: $123.00 Fees Paid: $123.00 Building Permit N/A OWTS Permit: SEPT -10-20-6536 Issue Date: 4CY.:Vz,zG, Balance Due: $0.00 Garfield County Public Health Department: 4.- E/‘ -c` d ,14"---:<-1' P E- WfoA E Signed Approval Date PD. $123.00, CC, 10/15/2020