HomeMy WebLinkAboutApplicationGarfield County
195 W. le Street Public Health 2014 Blake Avenue
Rifle, Co 81650 Glenwood Springs, CO 81601
(970) 525-5200 (970) 945-M14
QWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
_® New Installation _ ❑ Alteration ❑ Repair
BUILDING USAGE TYPE
® Dwelling I ❑ Translent Use
❑ Other Describe
❑ Comm./industrial i `-' . Non -Domestic
- - - -
Property Owner: CM Homes Inc
Phone: r 970 245-9039
Meiling Address: 67123 Road Grand Junction, CO 81505
Email Address• rtad,douglasCclaytonhomes.com/
Contractor: Clayton Homes
Phone: I 970 i 245-9039
MallingAddress: 67123 Road Grand Junction, CO 81505
Email Address: staci.douglas*claytonhomes.com.l
Engineer: Rhlna Engineering
Phone: ( 970 1 250-1181
MailingAddress: PO Box 1076 Grand Junction, CO 81502
Email Address: johnk@rhfnoengineers.com
P# WECT LOCATION AND DESCRIPTION
JobAddress: 5538 County Rd 309 Parachute, CO
Assessor's Parcel Number: 2173 3640 0028 Sub.
Lot Block
Building or Service Type: *Bedrooms: Garbage Dk posal(Y/N)
Distance to Nearest Community Sewer System: Several miles
Was an effort made to connect to the Community Sewer System:
Potable Water Source ® Well I Q spring I ❑ Stream or Creek ❑ astern
& Type ❑ Community Water System Name
Ground Conditions: Depth to 1 st ground water table I Percent Ground Slope
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 applfcation; 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 dental 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 Certiflcatlon above as
well as have provided the required Information which Is correct and accurate to the best of
my knowledge.
!- --6 • " Zit
Property Owner Print and Sign — Date
OFFICIAL USE ONLY
Special Conditions:
Paglt Fee: 00
r�
T.AI s.
123
FeV Paid' '�
i� 0
Building Permit
OWTS Permit:
Issue Data:
Balance Due'
�O
Garfield County Public Health Department:
signed Approval
date
Page 5 of
Updafed Dec 200