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 _ ] El Alteration
_BUILDING USAGE TYPE
® Dwelling L❑ Transient Use j 0 Comm./Industrial
❑ Other Describe
0 Repair
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Gilberto Manlanaz
Mailing Address: PO Box 3, sill, CO 81882
Email Address: olgemontanez40@gmail.com
Contractor: Affordable Builders
Phone: (670 ) 309-1970
Mailing Address: -802 Samoan Dr., Grand Junction, CO
Email Address: effordablebuller,gi@gmalLcam
Phone: ( 303 ) 420-2670
Engineer: Ken Bralsky
Mailing Address: 658 Rio Oso Lane Grand Junction, CO 81607
Email Address:
Phone:(
PROJECT LOCATION AND DESCRIPTION
Job Address: TBD CR 237, slit, CO 81652
Assessor's Parcel Number: 212736200080 Sub, ANTLERS ORCHARD Lot TR 28 Block
Building or Service Type; RESIDENCE #Bedrooms: 4 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System: NIA
Was an effort made to connect to the Community Sewer System: NIA
Potable Water Source
& Type
® Well 0 Spring ❑ Stream or Creek
0 Cistern
0 Community Water System Name
Garfield County Public Health Department — working to promote health and prevent disease
i 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
appiicaElan or revocation at 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.
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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
BLMF-11-20-6602
OWTS Permit:
SEPT-11-20-6603
Issue Date:
I 4 G/C0a
Balance Due:
$0,00
Garfield County Public Health
Department; ///L'&--
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Signed Approval
)
Date
PD. $123.00, CC, 11/20/2020