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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