HomeMy WebLinkAboutApplication195 W. 1.4th 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
Property Owner: Candace van Berlo Phone: (970 ) 274-0666
• New Installation
• Alteration 17
Repair
BUILDING USAGE TYPE
Contractor: Legacy Fxcavatlon LI C Phone: ( 970 ) 274.0743
rA Dwelling • Transient Use
0 Comm./Industrial
• Non -Domestic
• Other Describe
Engineer: Eldorado Fnglneeriag Company Phone: ( 303
) 945.8596
Mailing Address: p0 Box 669 Glenwood Springs. CO 61601
INVOLVED PARTIES
Property Owner: Candace van Berlo Phone: (970 ) 274-0666
Mailing Address: 176 Daisy Drive Carbondale CO 81623
Email Address: clace176@gmail.com
Contractor: Legacy Fxcavatlon LI C Phone: ( 970 ) 274.0743
Mailing Address: 172 Current Drive New Castle CO 81647
Email Address: Classicford79@gmail.com
Engineer: Eldorado Fnglneeriag Company Phone: ( 303
) 945.8596
Mailing Address: p0 Box 669 Glenwood Springs. CO 61601
Email Address: ?
PROJECT LOCATION AND DESCRIPTION
Job Address: 0176 Dalsy I ane Carbondale CO 81623
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
Sub.
Lot 12 Block
Single Family #Bedrooms: 4
Garbage Disposal(Y/N) Y
Sewer
to the
System: Town of Carbondale 7?7
Community Sewer
System: NO
Potable Water Source
& Type
NI well
❑ Spring
❑ 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.
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.
f:anrlarn van Rerin gazdazeUro 60.140.
Property Owner Print and Sign
O2!D8I2a21
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$75.00
Total Fees:
$75.00
Fees Paid:
$75.00
Building Permit
N/A
OWTS Permit:
SEPT -02-21-6685
Issue Date:
Ca-Az/49z. (
Balance Due:
$0.00
Garfield County Public Health
/ � �� z z
Department: // /,. �- - 11 /�� (�l. '–' i F r t lam(
Signed Approval - Date
PD. $75.00, CC, 2/9/2021
Page 5of3
Updated Dee 2013