HomeMy WebLinkAboutApplicationRECEIVED
'AUG a 2 2021
iiAk _l..0 COUNT) LOPMEN 3 Garf eld County
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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
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❑ Other Describe
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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
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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
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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
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