HomeMy WebLinkAboutPENDING Application195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
e. Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
EV' New Installation
❑ Alteration
BU J DING USAGE TYPE
Er' Dwelling
❑ Other Describe
❑ Repair
❑ Transient Use
❑ Comm./Industrial
❑ Non -Domestic
INVOLVED PARTIES
Property Owner: 0704.4 54 .4Zj .[ AP 4 Phone: (dI10 ) -7-• 4742, to
Mailing Address: (Q 74 �-'{1,-4.6.5 v,,,b4..1 'Paso�, e'er e i 62 2.4
/
Email Address: S" d r1r1rn to+�iiir mai I. .r)y1•'4 e iib yQ•li (Tv a cefil,
Phone: (gin) 1-t;36.9r)
5 Z
Contractor: -a 1llJA&r�'1 12,01_47e42.-
te f��
Mailing Address: P.O.l36-- I ' 6C: j 6.67Z -45 -4E. -.)Z-4 01&2-
Email Address: -�.r • e— i[/ , r 1 J 7Jy i:U.I 1 •i i Ct.iYi'-1
Engineer: triCIA.VTAI Vs eir--05 f *-4615rdik v 1' Phone: (q1O I./4s-. 65.44.
Mailing Address: 62-fc IL Z t'Zlad--{4L /1/4111E-. ) G11.a f] € 4Si Cei 8hc01
Email Address: C- (1 �&. ir1rI 1llGr. r Cvij . COya•l
PROJECT LOCATION AND DESCRIPTION
Job Address: � ire 12-0.16p, e,
Assessor's Parcel Number:2;M
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
133`}'Dee2 Sub. J64 . Lot Block
lE44Ii44--
#Bedrooms: 5 Garbage Disposal(Y/N) y
Sewer
to the
System:
Community Sewer
System:
Potable Water Source
& Type
NIX Well
❑ Spring
0 Stream or Creek
0 Cistern
0 Community Water System
Name
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 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.
Property Owner Print and Sign
,1lzaZ/
r-
ate
OFFICIAL USE ONLY
Special Conditions:
Per it Fee:
(Z3. o0
To 1 Fees:
I2-3 .00
Fees Paid: 4.
123.0
Building Permit
aorie .4,061
OWTS Permit:
SEK -1,(430
Issue Date:
Balance Due:9
Garfield County Public Health Department:
Signed Approval Date
PD.4 (23 •o, cc1 7.15 C? -v.2,1
Page 5 of3
l 'pdarted Dec 2013