HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
bile lifialth
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPfr OF SYSTEM CONSTRUCTION
New Installation ❑ Alteration ❑ Repair
131-3DING USAGE TYPE
Inv Dwelling ❑ Transient Use ❑ Comm./Industrial ❑ Non -Domestic
0 Other Describe
INVOLVED PARTIES !� /1 ! !
Property Owner: C�te f. "F £ f Ha. aci—kt 1 9 Phone: (G? %O } 3 0 c%- 575 9
Mailing Address: ;1i,4 FES Lt r fn,' 6,cr ( L) n V t 1e Jct f (it rho n r 6.) %c 008/0z
Email Address: OaOa1.40 . T1 6 -e /0 (ctit 1 (0-114
Contractor: f L"NL} t F}(( i tinJ l L 1?5"1"-4-41-
Phone: (q7C ) 37 9- 97 Z (e
JJ
Mailing Address:
Email Address: �t
Engineer: er a 0 In(-
, Phone; ( / 70 ) Q'9 12- jG}/
Mailing Address: C"!(3 Pc Li i' hi -1't�Q 1 ) n ve Pd (Oaf .O 1) /l/TCA ld r CO
Email Address: COf (et OSFk e . 9 (d) I L cv''.1
PROJECT LOCATION AND DESCRIPTION % /�
Joh Address: /..2-0 a")n- s 1. c vx Oc l k71J7-Ci Ci L P L 1 o.
Assessor's Parcel Number:2(�_r`-1 C// t? • Q/gub. /�) yo Y7 Pea k_ $' Lot / 0 Block
B uilding or Service Type: 1---(L9L'?. ' n #!Bedrooms: Garbage Disposal(Y/N} N
• to Nearest Community Sewer System: e i% ! Ll. ! Le S
Was an effort made to connect to the Community Sewer System: AID — I i 0 ! a Vo r t'C7 Ci l
Potable Water Source
& Type
El Well ❑ Spring ❑ Stream or Creek ❑ Cistern
eiommunity Water System Name / 1 h !N J? Pea !C�
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.
Carta 0694-e r9 at ti n_A?
Property Owner Print ari ign (� Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
BLRE-6571,
OWTS Permit:
SEPT -11-20-6573
Issue Date:
,1
12/4/2020
Balance Due:
$0.00
BLRE-6572
Garfield County Public Health
// /
Department:
f f W (
070
Signed 4proval
/
Date
PD. $123.00, CC, 11/9/2020