HomeMy WebLinkAboutApplication195 W. 14t" 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
0 New Installation C] Alteration ❑ Repair
BUILDING USAGE TYPE
® Dwelling j ❑ Transient Ilse ❑ Comm./Industrial ❑ Non_-Dornesttc
❑ Other Describe
INVOLVED PARTIES
Property Owner: WIIliamlEmily McCarty Phone: 970 456-9049
Mailing Address: 280 Lariat Lane, Glenwood Springs. CO 81601
EmaiiAddress: kenny@adstogo.com
RwA
Mailing Address: B15 Blake Ave, GWS, CC181601
Email Address:
Phone: ( 970. 945-0240
Engineer- Mountain Cross EnglneeringtChrls Hale Phone: ( 970. 1 945-5544
Mailing Address: 826 Grand Ave, GWS, Co 81601
Email Address: ahria@rriountainnross-eng_com
PROJECT LOCATION AND DESCRIPTION _
Job Address: 260 Lariat Lane, olenmod Springs. CO 51601 —
Assessor's Parcel Number: 239513101020 Sub. Teller Springs Lot 20 Block
Building or Service Type: residential #Bedrooms: s Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System: 5 miles
Was an effort made to connect to the Community Sewer System: No
- T
Potable Water Source I Q Well ❑spring ❑ StreamorCreek ❑ Cistern
$ Type 0 Community water system Name T WN, �—
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
i 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 1 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.
wi'WW k. Aca?te 111 6/22/21
Property Owner Print and Sign Date
OFFICIAL USE ONLY W pd.
Special Conditions:
Permit Fee:
4 kz3,ap
Total Fees:
* Its, �-
F s Paid:
1t23. W
Building Permit
9.110-RE-1,9 Nil
OwTS Permit:
SEPT-- 694 1
Issue Date:
zC2f
Balance Due: i
Garfield County Public Health Department:.:
Signed Approval
Date