HomeMy WebLinkAboutApplication-PendingRECEIVED
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GARFIELD COUNTY
C-O ttt ttt U H trY D EVE LO P M ENT
Public Heulth
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-66t4
OWTS PERM IT APPLICATION
Gurfield County
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration ø Repair
BUILDING USAGE TYPE
ø Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
PropertyOwner: Joshua Brewer Phone: ( gzoltz¿-a¿lg
Mailing 4798 CR 320
Email Address:irb798404@msn.com
Altitude LLC hone: ( 97ü471-0913
Mailing Address:PO Box 1534, Eaqle, CO 81631
Email Address altitudeseotictôoma il. com
Engineer: Phone:t)
Mailing Address:
EmailAddress:
PROJECT TOCATION AND DESCRIPTION
JobAddress: 4798 CR 320, Rifle, CO
Assessor's Parcel Number: 217534100083 Sub. Red 4pp!9 OlSlerd !9v lot Tr 14 Block
Building or Service Type: Residence fBedrooms:1!--Garbage Disposal(Y/N) N
Distance to Nearest Community SewerSystem I Miles
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
El Well tr Spring tl Stream or Creek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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.
Eu¡'tt¿tt-07t08t2022
Owner Print and Sign Date
Applicant acknowledges that the completeness of the application is conditional upon such further
mándatory 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 anyfalsification or misrepresentation may result in the denialof the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
oFFlclAt UsE oNLY P*t>. $ ?ç ê o - c . c. o7 loi/zazz ¿i.ã,
Special Conditions:
Perm¡t Fee:
$15Þo
Total Fees:| ?5.èê
Fees Paid:i 15.cs
Building Permit
NA
OWTS Permit:
s6P1- 7¿{E
lssue Date:Balance Due:+/
a
Garfield County Public Health Department
Signed Approval Date