HomeMy WebLinkAboutApplicationGarfield County
195 W. 14'h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, 00 81601
(970)625-5200 (970)945-6614
TYPE OF SYSTEM CONSTRUCTION
A New Installation ❑ Alteration ❑ Repair
BUILDING USAGE TYPE
_—_ — — —
Dwelling ❑Transient Use I ❑ Comm./Industrial I ❑ Non -Domestic
❑ Other Describe
Property Owner: Ea,((14 RAITER. f Ly J6 AG 1>0 Phone: l�p�)� I l � *✓��
Mailing Address:, 17710 Ce , 60c-?,
Email Address: E IGfrtIMA-e- GoL.o12 G0l L.(A• "m
Contractor: Phone:
Mailing Address:
Email Address:
Engineen,66P_" DSJ1$k.Lj1GBo SkP74 Phono:(�?a1 Z59
Mailing Address:9&1 66tife.) AR— B'7 _O &/&z.3
Email Address: G694A • 054'BeX4 GJ 4AAAIL
PROJECT LOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel Number:: 2 3 9I IY,10 A7ZS Sub. / bdl _Lot / Block PAILCU l
Building or Service Type; 4AJ 61 "7 PkJb0.- NBedrooms:--a—Garbage DIsposal(Y/N)_:6�a_
Distance to Nearest Community Sewer System: > 5 44"14cs
Was an effort made to connect to the CommunitySewer System: W/A
-
Potable Water Source I P, Well ❑ Spring 6 Stream or Creek ❑ Cistern
& Type ❑ Community Water System Name
Garfield County Public Health Department— working to promote health and prevent disease
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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
knowledge,
Proper4 Owner Print and Sign Date
OFFICIAL USE ONLY PA 12-3.
CK'*13GS lbr. ag/20Xk
Special Conditions:
Permit Fee:
�IZ3.44
Total Fees:
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Fees Paid:
# 123.oa
Building Permit
Cog) E•
dwTS Permit:
Pr- Sr- 09 03
St
Issue Date.
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Balance Due -
Garfield County Public Health Department:
Signed Approval
Date