HomeMy WebLinkAboutApplicationGaffield County
195 W. L4th Street
Rifle, CO 8L650
(970) 62s-s2OO
Pu*íå* X{e*{tÍt
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
ß70194s-661.4
RECEIVET)
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GARFIELD C OUNTY
MËNTWPE OF SYSTEM CONSTRUCTION
ø New lnstallation ! Alteration fl Repair
BUILDING USAGE TYPE
Ø Dwelling E Transient Use fl Comm./lndustrial Non-Domesticn
E Other Describe
INVOLVED PARTIES
Property gu¡¡g¡3 Henryr Domuiue / Jorf¡e Lopez Phone:- q87- .-i4üç
Mailing OOOr"rr'175 \Arest 9ırd St'Apt 12h' New York NY 1OOO25
Email Address: hdomville@yahoo'com
Cont e:
Mailing Address:
Email Address:
Engineer: GarlaOstber€/ GBOInc. p¡one: ( gzo).3og-Resg
Mailing Address;139 Cains Lane, carbondaJe CO 816eı
Email Address:carla. ostberg@Élmai]. com
PROJECT LOCATION AND DESCR¡PTION
Job Address:Panorama DR. and. Bsalt Mountain Dn
Assessor's parcer Number.a59l't?I-olaa tro. Panorama Ranches [ot?? Block _
Building or service Type¡ New resid'ence #Bedrooms: ? Garbage Disposal(y/N¡ Yes
Distance to Nearest Community Sewer System:? Miles
Was an effort made to connect to the Community Sewer System:No, too far
Potable Water Source
& Type
Ø Well E Spring I Stream or Creek E Cistern
fl Community Water System Name
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. 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
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Property Ow ner Print and Sign
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Date
oFFtctAL usE oNLy PAID $¡.23,êê €. (. atrlot /?-c¡77¿þ
Special Conditions:
Perm¡t Fee:t lz3,æ
Total Fees:ln3 oô Fees Paid:
.+ 123.oo
Building Permit
BLRe -1919
OWTS Permit:
Se"T'15 (o o
lssue Date:Balance Due:.t/
Garfield County Public Health Department:
Signed Approval Date
? agt í.: t:í 3:
T.i ytaê.*t*<i l3* 2l!13
06/29/2022