HomeMy WebLinkAboutApplication1-95 W. 14th Street
Rifle, CO 81650
(970) 62s-s200
Public Heslth
RECEIVED
MAY ? 5 2T2?
ti¡TRFIELD COUNTY
TOMMUNITY DEVELOPMENT
20L4 Blake Avenue
Glenwood Springs, CO 8160L
(970)94s-66r4
OWTS PERMIT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration tr Repair
BUILDING USAGE TYPE
tr Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
I Other Describe Temnnrarrr Varrlt ¡l lJarrl fnr Temnnranr Fmnlnrrpp l-{aucins
INVOLVED PARTIES
Property Couey Family LLLP e:( 970 ) 618-3668
Mailing Address 6275 COUNTY ROAD 315 silt, co 81652
EmailAddress:
coueyranch@gmail.com
Re Laramie En , LLC one:(970 ) 812-5310
Mailing Address
Email Address:
760 Horizon Drive Suite 101, Grand Junction, CO 81506
wbankert@ lara mie-energy.com
Engineer: Phone )
Mailing Address
EmailAddress:
PROJECT TOCATION AND DESCRIPTION
Job Address:Lot 11 Section 3, Tow hio 6 South. Ranee 97 West- COGCC WellPad CC697-03-07
Assessor's Parcef Numbe t' 2769 - 022 - oo - 030 sub.-Lot-Block
-Building or Service 1ro"' Temp' Housing #Bedrooms?:lYrrative Garbage Disposal(Y/N) N
Distance to Nearest Commun¡ty Sewer System 14 mapped miles
Was an effort made to connect to the Community Sewer System No
Potable Water Source
& Type
tr Well E Spring E Stream or Creek fl Cistern
tr@ Water hauler - see Narrative
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional _rpo.n such further
niandatory and additinnal tests and reports as may be required by the local health department to be
made and'furnished by the applicant or by the locàl 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
neceis'ary to insure compliance with rules and regulations made, information and.reports submitted
herewith'and required tò 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.
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.
) rt7)** I d"",// Mav r9th,2o22
Property Owner Print and Sign Representative Date
OFFICIAL USE ONLY ?¡tO .*zln * c.c.. aâ/zs/zoz?_ Aæ
Spec¡al Cond¡t¡ons:
Permit Fee:
$ 11. "o
Total Fees:
+ 15.oo
Fees Paid:{ '?5. ""
Building Permit
N/e
OWTS Permit:
se?T -'? 551
lssue Date Balance Due:*l
Garfield County Public Health Department:
Signed Approval Date
06/16/2022