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HomeMy WebLinkAboutApplication195 W. 14th Street Rifle, CO 81650 (970)625-5200 Garfield County 1`1111111ow Public Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970)945-6614 OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION 13 New Installation ❑ Alteration I ❑ Repair BUILDING USAGE TYPE {7 Dwelling 1 ❑ Transient Use ❑ Comm./Industrial []Other Describe INVOLVED PARTIES Property Owner; Thomas Fisher/Colleen Hause Mailing Address: 1090 Fender Lane, Carbondale, Co 81923 ❑ Non -Domestic 970 1 309-0814 Email Address: tomfisher@rocketmail.rom Contractor: Home owner Phone; ( 1 Mailing Address: Email Address. Engineer: Carlaostberg Phone: ( 970 i $09-5259 Mailing Address: 129 rains Lane, Carbondale, CO 81623 Email Address: carla.oslberuCcimail.com PROJECT LOCATION AND DESCRIPTION Job Address; TBO Basalt Mountain or Z3 II(. 01016 ASSeSSOr'S Parcel Number: 09800=00 Sub, Panorama Ranches Lot 16 Block Building or Service Type: Residential #Bedrooms: 4 Garbage Disposal(Y/N) n Distance to Nearest Community Sewer System: miles Was an effort made to connect to the Community Sewer System: no Potable Water Source i ❑ Well ❑ Spring i ❑ Stream or [reek ❑ Cistern & Type 0 Community Water System Name Panorama Ranches 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 bylaw. 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. Thomas D Fisher- D Property Owner Print and Sign 6/912©21 Date OFFICIAL USE ONLY Pd 417.3.°° cc 0(/i!AA2-k special Conditions: Permit Fee: d 1 Z,3 .-. Total Fees: t 12-3 -* Fees Paid: $1 7-3 .160 Building Permit OMITS Permit: Issue Date: .�1 Balance Due: 5�.&E.491t s"r-0%3 Paz fa ` Garfield County Public Health Department: Signed Approval Date