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. [ 0 Alteration ❑ Repair
BUILDING USAGE TYPE
E
Dwelling ❑ Transient Use j ❑Comm./Industrial ❑ Non -Domestic
CI Other Describe
L. -- —
INVOLVED PARTIES i ._--
Property Owner. J ,E11, LEONARD 2 01 4 DYNASTY '7 F1'tyif(
Email Address: JOELTLEONARD@ GMAIL . COM
Contractor: E and . XCavaf[011 Phone: (719) 3 95 6 764
Mailing Address; 28005 CR 317 Buena vista CO 81211
I Email Address: Ilsasnslprecast.com
I Engineer: HIGH COUNTRY ENGINEERING, INC Phone:( 970) 945-8676
Mailing Address: 1.517 BLAKE AVE SUITE 1.01 GWS CO 81601
: Email Address:
RNEALC®HCENG.COM
,PROJECT LOCATION AND ptSCRIPTION
I Job Address: 1679 CR 245, NEW CASTLE CO 81647
Assessor's Parcel Number: 212 52 53 0 007 7 Sub.
Building or Service Type: OWTS ((Bedrooms: 4 Garbage Disposal(Y/N)
Distance koNearest Community Sewer System: 1.4 MILES
I Was an effort made to connect to the Community Sewer System:
Potable Water Source IS Well 0 Spring Q Stream or Creek 0 Cistern
Lot Block
NO
& Type ❑ Community Water System Name
i I
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.
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 kno►grledge.
CL
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
BLRE-6471,
OWES Permit:
SEPT-11-20-6574
Issue Date:
[ (M/Z8 p
Balance Due: $0 00
BLRE-6472
Garfield County Public Health
Department: ' L 0 / ' ` 117/Vecza
__
Signed Approval Date
PD. $123.00, CC, 11/9/2020