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HomeMy WebLinkAboutApplicationRECEIVED 'AUG a 2 2021 iiAk _l..0 COUNT) LOPMEN 3 Garf eld County Gpk,,.„„1 ry Df;VF.LOPMEN Public Health 195 W. 14fh Street 2014 Blake Avenue Rifle, CO 81650 Glenwood Springs, CO 81601 (970)625-5200 (970)945-6614 OWTS PERMIT APPLICATION E OF SYSTEIVI UONSTRUCTION New Installation - ❑ Alteration 1 ❑ Repair w LDIMG USAGE TYPE - welling �, ❑ Transient Use ❑ Com./Industrial ❑ Non -Domestic Dm ❑ Other Describe IIVVULVCU rAKIILb Property Owner: GLENN BEATON Phone: ( 720 ) 299-7478 Mailing Address: 2001 LINCOLN STREET UNIT 2513, DENVER CO 80202 Email Address: GKBDENVER@GMAIL.COM Contractor: RIDGE RUNNER CONSTRUCTION Phone: ( 970 ) 045-5543 Mailing Address: 1665 CO RD 109 GLENWOOD SPRINGS CO 81601 Email Address: BLRIDGERUNNER@GMAIL.COM Engineer: CARLA OSTBERG _Phone: ( 970 ) 309-5259` Mailing Address: 129 GAINS LANE, CARBONDALE 00 81623 Email Address: CARLA.OSTBERG@GMAIL,COM Job Address: 124 JUNIPER DRIVE, GLENWOOD SPRINGS C081601 Assessor's Parcel Number: 218536312001 Sub. ELK SPRINGS LOS AMIGOSFLG 8 PH-2 Lot RR1 Block Building or Service Type: SINGLE FAMILY RESIDENCE #Bedrooms: 2 Garbage Disposai(Y/N) Y Distance to Nearest Community Sewer System: NA I Was an effort made to connect to the Community Sewer System: NA ❑ Well ❑ Spring ❑ Streamor Creek ❑ Cistern & Type —�—--------- A Potable Water Source YP !Comunity Water System Name ELK SPRINGS HOA Garfield County Public Health Depaiiment - working to promote health and prevent disease 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 wl] 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 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 my knowledge. Property Owner Print and Sign ate M A _ � yY i ii S! � 'L -4i1� �'.a3�- 1ii'#t `�.w,.a. f5•� `Y�r Li L; _-�e"ry-�S.'�� . `�i�-�����aTk.�,•� S� �. �d�'�'�'f •l.c��f � �' - � .,-� f � i'�t �k l ,�r.. � � �-;: � Y .3n 5F Special Conditions - Permit Fee- 1 12-Is .4-0 Total Fees: If 12,13. V Fees Paid: 4 113 Ito Sullding Permit OWTS Permit: Issue Date: Balance Due: ZApproval Garfield County Public Health Department*. . SPg�ed Date I Eiclaud tkr?i!E?