HomeMy WebLinkAboutApplicationE4 Garfield County
195 W. 14t" Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
WTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New installation 1 ❑ Alteration J ❑ Repair
BUILDING USAGE TYPE
Dwelling ❑ Transient Use ❑ Comm.Jlndustrial �_❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: Andrew E;.41 �-er _ Phone
Mailing Add ress:_361Z5 9:pple,ei70d S�,.._ Grand - nC on CO 815oi�
Email Address: a n d rim W S E t I iy e• C Qi'y 1
Contractor: - ---- Phone:
Mailing Address:
Email Address:
Engineer:KuI'tr1ILIA OAd P6$0Uck.,5 , ty1G• Phone:
Mailing Address: v 2-0 u un Ko a ci` l 5 y C 1 n wWO r-I n 9) (o D l
Email Address: l c�q IP.rlwond @ klAn4 ar uSu . Cory)
PROJECT LOCATION AND DESCRIPTION
Job Address: q (ARoad (P S i i + O 851 (105-L
Assessor's Parcel Number- 21'LlL(040$03$ Sub. Wd Su% f'�f Lotq�Block
Building or Service Type: -ReSiAerrHa i „ _ _ #Bedrooms: 3 Garbage Dlsposal(Y/N)�
Distance to Nearest Community Sewer System: N A
Was an effort made to connect to the Community Sewer System: Nit*
Potable Water Source t$ Well ❑ Spring ❑ Stream or Creek ❑ Cistern
& Type ❑ 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 hest 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 bylaw.
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the required
my knowledge.
�YZW 1:-(A V-e lr
Property Owner Print and Sign
which is correct and accurate to the best of
- b5 - 2-a -zo2k
Date
OFFICIAL USE ONLY
Pd = I2-7-W PC • C6 ` sotl
Speclal Conditions:
Permit Fee:
*113 . °=
Total Fees:
4 123.6-0
Fees Paid:
4123, o-0
Bullding Permit
OOWTS Permit:
Issue Date:
Balance Due:
4ee
(0971
.7EP1 72.
Garfleld County Public Health Departmen
Signed Approval
Date