HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Gar, field County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
Property Ownerr, Marlo Tarin Phone•{ 970) 618-64.86
Ll New Installation
❑ Alteration
1
0 Repair
BUILDING USAGE TYPE
Mailing Address: ...671 23 Road Grand Junction, CO 81606
® Dwelling I ❑ Transient Use
■ Comm./Industrial
Engineer: -CIVCC ennlneedno Phone: ( 435 t 789-5448
I ■ Non -Domestic
• Other Describe
PROTECT LOCATION AND DESCRIPTION
Job Address: 405 County Rd 104 (Blue Rd) Carbondale, CO 81623
N
Assessor's Parcel Number:2393-2520-0271
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
INVOLVED PARTIES
Property Ownerr, Marlo Tarin Phone•{ 970) 618-64.86
Mu91IngAddress: PO Box 1098 Carbondale, CO 81623
Email Address:
Contractor: Clayton Homes - Phone: ( 970 ) 245-9039
Mailing Address: ...671 23 Road Grand Junction, CO 81606
Email Address: stacl.douglas®claytonhomes.com! -.-..
Engineer: -CIVCC ennlneedno Phone: ( 435 t 789-5448
MallingAddress: PO Box 1758 Vernal, UT 84078
Email Address: _vanceking@dvcoengineering.com
PROTECT LOCATION AND DESCRIPTION
Job Address: 405 County Rd 104 (Blue Rd) Carbondale, CO 81623
N
Assessor's Parcel Number:2393-2520-0271
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub.Jean & Dee Blue Amended lot2 Block_
Single Family Residence Hgedraoms: 3 Garbage Dlsposal(Y/N)
SewerSystem: Several miles
to the Community Sewer System: No
Potable Water Source
&TYPe
lid Well ❑ Spring ❑ Stream or creek O astern
—s-�.—
0 Community Water System Name
Ground Conditions: Depth to 1st ground water table
/ Percent Ground Slope
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. 1
further understand that any falsification or misrepresentation may result in the dental 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 .
Property Owner Pr rtan —
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
II23.00
Total Fees:Fees
1-123.60
Paid:
112.3. 00
Building PermitOWTS
'
Per=1t:
lData: �L
ti i
Balance Due:
Garfield County Public Health
1 1..
Department; -- C;•- 0 4/22. Ze/e_6
Signed Approval Date
173.0o) 592001-0 ► f 13 ! 2trtI
Page 5 of 3
Updated Dec 2013