HomeMy WebLinkAboutApplicationRECEIVED
-� Garfield County
G�,F2Fl�Li� coUNrY Public Health
Comm '"iiT��'--feWjet 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
& New Installation
BUILDING USAGE TYPE
�77 Dwelling ❑ Transient Use
❑ Other Describe
❑ Alteration
❑ Comm./Industrial
❑ Repair.
❑ Non -Domestic
i INVOLVED PARTIES %
Property Owner: - i L a '`' Af 7, a e, Phone: Fj
> C'
Mailing Address: a _'� Q C 1 (e� 45
Email Address: f �.1, t j i P / / C
Contractor: ��� CI� Phone: (P�) 1 (t S -'' 1r7 z C]
Mailing Address:
Email Address:(( Ply% �. �L1 �— 1'f c�L1 �(
Engineer: CA rLLA Oyr ft F Rb Phone.-( J'70 1 Q 9 ' 7259
Mailing Address; 129 GIN 'a I -A N& CA2f5oA1DA%,C. to R167-7
Email Add ress:rLO,rIQ.- 6 9 t 6 9 r 5 @ arrlc t t-?V M
PROJECT LOCATION AN DESCRIPTION , 4 % /
Job Address: �' r !'� y 4 uJV�I Cl ;1
- - -- - -
Assessor's Parcel Number: 23Q32-410 01-1 S, b. e Ia t Block
Building or Service Type: S 7I YZ �� fA #IBedrooms: Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source B well ❑ Spring ❑ Stream or Creek
&. Type ❑ Community Water System Name
❑ Cistern
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 by law.
I hereby acknowledge that I have rear) 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. %
&� I L L Z-o z-
Property Owner Print and Sign Date
OFFICIALUSEONLY
Pd la3 +a Cc c fo 1zw
Special Conditions:
Permit Fee:
Total Fees:
Fees Paid:
-412.3.06
$123.00
0(Z3.ell,
Building Permit
OwTS Permit:
Issue Date:
Balance Due:
aa4.R E — 7 o 31
SEPT - '70
I�
Garfield County Public Health
Department: F
Signed Approval
Date