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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 El New Installation BUILDING USAGE TYPE E7 Dwelling 0 Transient Use 0 Other Describe 0 Alteration 0 Repair 0 Comm./Industrial 0 Non -Domestic INVOLVED PARTIES Property Owner: Chevron use Inn Mailing Address: Po Box 285 Houbton, TX 77001 Phone: } Email Address: Contractor: TEP Rocky Mountain LLC Mailing Address: PO Box 370, Parachute. C081635 Email Address: KMcIntosh@terraep corn 1 BHotard©terraep.com Phone: (970 ) 285-9377 Engineer: Fox Engineering Solutions inc Mailing Address: 670 Canyon Creek Drive, Grand Junction, C081507 Email Address: ooloradofox®bresnen not Phone: (970 } 250-5505 PROJECT LOCATION AND DESCRIPTION Job Address: GM 12-20 Pad Assessor's Parcel Number: 217118200008 Sub. Lot Block Building or Service Type: Small Temporary Employee Housing #Bedrooms: 7 Garbage Disposal(Y/N) N Distance to Nearest Community Sewer System: NA Was an effort made to connect to the Community Sewer System: Potable Water Source IDWell 0 spring ❑ Stream or Creek & Type ii Community Water System Name crty or Knee Cistern 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 l 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. Ati Ott %fi' Property Owner Print and Sig at OFFICIAL USE ONLY Special Conditions: Permit Fee: $75 �� Total Fees: $75.00 Fees Paid: $75.00 Building Permit OWTS Permit: SEPT-11-20-6593 Issue Date: (14 glzdL , Balance Due: so.00 Garfield County Public Health 9 l6A^zi jt'J f Department: � `� "� �it / btlki:O Signed Approval ' Date PD. $75.00, CC, 11/19/2020