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HomeMy WebLinkAboutPermit195 W. 141h Street IMEW Public Health 2014 Blake Avenue Rifle, CO 81650 Glenwood Springs, CO 81601 (970)625-5200 (970)945-6614 OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION- New Installation L� Alteration-^�� ❑-Repair BUILDING USAGE TYPE _- Dwelling__ ❑Transient Use ❑ Comm./Industrial ❑ Non -Domestic _ El Other Describe _ INVOLVED PARTIE _ _ _ R PropertyOWned'"{.L�,�`tt,(�,(�� ��^^-�, Phone((�(�,)� --'--- MallingAddresstl d V ' i` Email Address: -LLkI Y t 71 q �\ C-0 in _ Mailing Address: Email Address: Engineer: T Phone: (_ 1 Malling Address Email Address ----- --- — — —--------- — —---------- --- .. -- — -- — PROJECT LOCATION AND DESCRIPTION Assessor's Parcel Number:1.jFj`q" (7-lNSub. Lot—Block— Building ot Block— BuildingorServiceType:`14A(P. P. YY]iYlilt._+_11¢edrooms: Garbage Disposal(Y/Ql_N_ Distance to Nearest Community SewerSystem: (1 A Was an effort made to connect to the Community Sewer System: yF� Potable Water Source ❑Well ❑Spring ❑Stream or Creek Cistern & Type ❑Community Water System Name Garfield County Public Health Department— working to promote health and prevent disease CERTiFICATIDN 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 matte, 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 th€�qed information which is correct and accurate to the best of my kno edge. 6pertv%wner Print and Sign �f OFFICIAL USE ONLY Special Conditions: Date Permit � ee:3 oo Total Fees: t12-5.01D 1� '� Fees Paid: . IDO +� Building Permit OWTS Permit: Issue Date: Balance Due: Garfield County Public Health Department: Signed Approval Date CANT fS VMD F*V0100) P M ?W."- J 17,3.0© kFPOA-wAl Li'C xN-"