Loading...
HomeMy WebLinkAboutApplication195 W. 14rh Street Rifle, CO 81650 (970)625-5200 Ga�fzeld County Public Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970)945-6614 TYPE OF SYSTEM CONSTRUCTION ❑ New_ installation 0 Alteratl BUILDING USAGE TYPE n 8 Dwelling -❑ Transient Use ❑ ❑ Other Describe u nm /Industrial ❑ Non -Domestic rnvuwcu rwa uca Property Owner:Thompson Femtiy Trust • Michael J and Susan - Phone; 92( 6 —) 399-2258 MailingAddresS:477 CR 112, Carbondale, CO 81623 Email Address: mlthomps0n1980@9mall.c0m Contractor: Pttone; 1__�J Mailing Address: Email Address: Engineer: Designer/Carla OsiberglC90 lnc. phone:( 970 i 309-5259 Mailing Address: 120 coins Lane, Carbondale, Co 81623 Email Address: coda.0stberg@gmail.com PROJECT LOCATION AND DESCRIPTION -- _.__- . .._.__. _.._ lob AddreSS: 477 —CR 112, Carbondale, CO 81823 Assessor's Parcel Number:2393-234.00-361 Sub, Lot Block _ Building or Service Type: residential #Bedrooms:5 Garbage Disposal(Y/N) n Distance to Nearest Community Sewer System: greater than 5 miles Was an effort made to connect to the Community Sewer System: No Potable Water ® Well ❑ Spring ❑ StreamorCreek (�❑ Cistern &Type ❑ CommunityWaterSystemName Garfield County Public Health Department — working to promote health and prevent disease CERTIFICATION i 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. —1 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 �ym�y knowledge. %%fyYlx /- - -/ 3/Z. z1 .Property Owner Print and Sign Date l c�a� l �. �d .ft�,✓ OFFICIAL USE ONLY Pal 41ren �jC� ZZZ3 6d/t3/ Zoa � a,� Special Conditions: Permit Fee: Total Fees: Fees Pa id- -Building Permit OWTS Permit: issue Date: Balance Due: MIA SWPT• Garfield County Public Health Department: / "N�l�✓� ['' © c'� TG'` Signed Approval Date