HomeMy WebLinkAboutApplicationRECEIVED
:,i:i ' ii '| 'l\',,'
:'
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
195 W. 1.41h Street
Rifle, CO 81650
(970) 62s-s200
Public Hesltlt
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
Garfield Coanty
E New lnstallation ; E¡ Alteration trRe lr
BUITD¡NG USAGETYPE
E Dwelling i El Transient Use tr Comm./lndustrial tr Non-Domestic
tr Other Describe
IM'OLVED PARNES
Property Owner 970 416-7127
MailingAdd 581 CR241
Email Address¡ "Stwe Beckb¡r
To be dot m¡md
MailingAddress
EmailAddress:
Engineer: Phone:ß70 ) 704 o31l
MailingAddress:602 Msin Sbæt, Suil8 43, C5Éonûlt, CO 81823
.,i
I
i
1
I
Email AddreSS: ¡utlsdse@eoprisils.m
PROJECÌ TOCAT¡ON AN D DESCruPI|ON
JOb AddreSS: 581 Cilnly Rd 241, l,lðw C$tlô 8lô47 {wEsT slDE oF CREEK)
Assessor's ParCel NUmbe¡;21252,ûl)0013 md 01e $uþ, PAoARIñA RANC LOt MeB BIOCk
Building or Service CAMPGROUND t¡lA Garbage Disposal(Y/N) m
, Distance to Nearest Community Sewersystem:> 2 m¡la
Was an effort made to connect to the Community Sewer System;NIA
I Poteble Water Source Elweu ,ESpring E Stream or Creek E Cistern
ll Community Water System Name ELK CREEK CAt¡FcROUNÐ& Type
Garfield County Public Health Department - working to promote health and prevent disease
CERNFrcANON
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
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 repoñs submitted
herewith and required to be submitted by the applir:ant 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.
q I Plz>
Owner Print and Sign Þ LLc-Date
OFFlclAt USE oNtY p,\r Þ . * l1rp. C ,C . O9 f zrlzozz ap+U
5pecial Conditions:
Permit Fee:trzg.^Total Fees:* lz3,.c"
Fees Paid:* lz3.æ
Building Permit
¡V¡
OWTS Perm¡t;
5eP1- 1815
lssue Datel Balãnce Due:+l
Garfield County Publ¡c Health Departmenti
Signed þproval Date